Laxative for Bowel Management: Pediatric Bowel Management 2013

Learn I'm just gonna show very quick how we do our protocol treatment with laxatives and uh our huge population are patients with anorectal malformation, patients with idiopathic constipation, and as we mentioned before, patients with Hisprung that have an intact anal canal and suffer from constipation. So our protocol is very simple and. Very straightforward and as I mentioned before, 85% of our kids respond to this protocol. It's the same thing we start with a contrast enema, no barium and no bowel preparation, and it takes us one week to find the amount of laxative that each child needs to empty his or her colon on a daily basis. So here's a characteristic image of a patient with idiopathic constipation and just by looking at this contrast enema, we know that we are not dealing with a patient with Hirschsprung's disease because remember that in a in a Hichsprung's disease, we have a non-dilated colon and then a dilated. Portion and in these patients with idiopathic constipation we see the dilation all the way down in the pelvis so those are the typical image of a patient with idiopathic constipation, a concept that is very important is that the laxative dose must be adapted to each specific patient. We never give laxatives to a patient that is fecally impacted. We like to say that if the patient is fecally impacted and you give laxative, they are gonna have the worst cramp of their life and they are probably not gonna come back to you. So we first disimpact the patients and then we determine what's the laxative amount that they need. So our disinfection protocol, we use 3 enemas per day for 3 days. We combine normal saline and fleet, normal saline and glycerin, and normal saline and soap, and after 3 days we get an abdominal X-ray film. If the abdominal X-ray film still shows infection, we admit the patient. In the hospital, nasal gastric tube and Golightly solution for 2 days. If the patient remains impacted, that's when we're gonna do a disinfection under anesthesia, but luckily most of the patients are disinfected with the 3 enemas per day for 3 days. I would say that we have to disinfect under anesthesia maybe. One patient per year in Cincinnati, it's extremely rare that this happens and again on Friday, based on the contrast enema and the dilation of the colon we guess a dose to start on Friday we always use senna laxative we think that it's more predictable and it's a stimulant as Doctor Norco mentioned. And we tell the parents on Friday that we're gonna start, for example, with 2 squares with Exlax. If the patient has diarrhea on Saturday, that means that 2 squares were too much, so we're gonna decrease to 1 square.5 for the Saturday dose. On the other hand, if the patient in 24 hours does not have a bowel movement that day we. Give an enema to get rid of the stool that the patient produced on that day and we increase to 3 squares of Ex-Lx. It's very important that while you're trying to determine the amount of laxative that your patient needs, that you empty the colon either because the patient had a bowel movement or because you give enema. Otherwise the patient can again get infected in front of your eyes and you don't want this to happen. And we give fiber, usually we use pectin or Citrucel just to give more bulk to the stool, especially in patients with anorectal malformation, they are very sensitive to liquid stool, they cannot control that, so they need this better consistency and that's the laxatives that we have here in the United States, the Ex-Lx, the chocolate squares and the little tummy, that's the liquid Senna. And during the period of one week we get an abdominal X-ray film to see how much the patient is stooling, how much stool there is in the colon, and based on that and on the report of the patient, we increase or decrease the laxatives or increase or decrease the fiber accordingly. So now we can move to the case discussions. And we will answer all the questions that you can possibly have. Yeah, let me just say, say, say something. Um, uh, Doctor Nurco, very, very nice seeing you. Um, it's a pleasure. Um, we want to emphasize that we only use laxatives in patients that are continent or have potential for bowel controls. We don't use laxatives once we declare that the patient is incontinent, we only use enemas because laxatives will just make the patient worse. So when the patients have potential for bowel control, we discuss that early in the morning when they have a normal sacrum, a good operation and constipation, we suspect that the so-called incontinence actually is pseudo incontinence and we subject the patient to what we call laxative trial that Doctor Bishop just discussed. If the, if the patient, when we give laxatives, we, the patient, uh, suffers from incontinence, that means that he's not ready for laxatives and we go for bowel what we call bowel management with enemas, and we never mix laxatives and enemas because it doesn't make sense for us because the with the we the purpose of the bowel management is to clean the colon with an enema and then to maintain the colon quiet for 24 hours until the next enema. OK, so we're good to start the case discussion everybody be ready to participate because that's your last chance to get all the answers correct so I'm gonna advance the first slide. So the first one is an 8 year old male patient with idiopathic constipation. Go ahead. My slide went back. So here's the contrast enema. Pre and post evacuation. And then 24 hours after the contrast enema, the patient comes to us in clinic and we can see that there is still some contrast left. So the first question that I'm gonna ask, do you think that this patient is fecally infected? Does he need um disinfection protocol? So you can answer one for yes, two for no. Everybody can answer. Wow, it's going all over. Some saying yes, some saying no. Now I'm getting more no wow. So let's go back. What is the impaction? Unfortunately we cannot ask you to point and show us exactly where is the infection, but what I see is just contrast. I don't see any fecal material in the rectum, so for me this patient is not fecally impacted this patient just has residual contrast, so I don't think this patient needs. Disinfection protocol I think we can just start trying to determine the amount of laxative that he wants that he needs. So Monica, how much laxative do you want to start him on? 2 squares of Ex-lex, 3 squares of Ex-lex, 4 squares, 5 squares, or 6 squares? How old is the patient? Patient is, I don't remember, I think 10 years old. 8 years old. Yep. 8 years old and. What do you wanna do, Monica? Just 2. So Monica said to start with 2 squares of X leg. So that would be option number 1. Some people said start with 3 squares. That would also be correct. Everyone in the, uh, audience chat in the global cast chat is saying 12, which is 2 squares of X of xx. It's because they heard Monica. But there's no problem if you start with 3, that's fine. If the patient has diarrhea, you just decrease the next day. So the good thing about having a week is that you don't have to always get right at your first choice. So let's say we pick 2 and on Monday the patient had 2 voluntary bowel movements and that's the X-ray that we have now. So do you think there is more stool that we want? It's OK? And whenever you're comparing X-ray, just compare with your previous x-rays. So remember that in your previous. Previous X-ray we didn't have much stool we only had contrast material and now we're seeing an X-ray in which we see a lot of stool and the patient had two voluntary bowel movements, no diarrhea, so the question is what do you wanna do? Increase the laxative dose, decrease the laxative dose or stay the same? Oh. So how are the people over there? So most people are saying increase the laxative dose. I agree. I think we should increase the laxative dose so we did increase and the next day here's the X-ray and the patient again had two voluntary bowel movements. So now looking at the X-ray we have almost perfectly clean rectum, some stool in the left column which is a. Good x-ray for a patient on laxatives. So, the question is, what do you want to do? Increase the laxative dose, decrease the laxative dose or stay the same? How many bowel movements did he get? Two voluntary bowel movements. OK. No diarrhea. No diarrhea. OK. So, we're getting a lot of threes here, staying the same. So, here also a lot of threes. So, most people are staying the same. I think this is a good decision. And again, if you're wrong, you're going to see the next day. So, on Wednesday, patient had three voluntary bowel movements and the x-ray looks good. And I think we're, we got the point. So now let's go to a 7 year old male patient, and here's the x-ray that he comes on a Friday. So, what do you think about this x-ray? Do you think this patient needs disinfection protocol? Yes or no? Laxatives. Some people are voting 3, but we don't have the 3, just 1 or 2. And people are saying yes we need a disinfection protocol no question this patient absolutely needs our disinfection protocol and we want him to be completely clean before we start the laxatives. So let's say that you did 3 days, now you have an X-ray and the patient is disinfected, so how much laxative do you want to start him on? 3 squares of X leg, 4 squares, 5 squares, 6 squares, or 7 squares of XL? You're getting a lot of ones. A patient will need needs 51 I'm going to go with 5. This, this patient had a huge infection. So, starting with three squares, you can start it and you will see the next day, but I think three squares would be too low. So, Monica and Doctor Pena are saying to start with 5 squares. I think that would be a good start. But again, if you think 3 will be enough, try 3. And see what happens the next day and follow the X-ray and you will be able to find the right dose that the patient needs. So we started with 5. The patient had 3 voluntary bowel movements with liquid consistency. I told you. So what do you want to do now? What did you say? I told you so. So Doctor Oshaus thought that 5 was too much. So what do you want to do now, Doctor Oshaus? Uh, I'd, I'd go a little bit lighter. OK. Uh, and, uh, add some fiber. Hm. Very good. So, we can decrease the laxative dose and add fiber. Yes. No, I think the patient is still partially impacted in this X-ray. So, um, I think, uh, either you increase the amount of laxatives at, at risk of giving cramps or give an enema plus increase the amount of laxatives, we don't have a pointer to show it all the stool that is accumulating. There or it's not emptying yet. So even when a patient has a liquid stool, if you see evidence of a solid stool like in this field, that means that the patient is having paradoxical diarrhea, is having liquid stool around the formed stool there. And let's see what happens, what, what, what happens. But according to this scenario that just changed a little bit. Yes. We were actually doing good because the patient had three voluntary bowel movements. The stool was less than the previous x-ray. So, our idea was just to decrease the laxative and add fiber. So, that was the idea. But if we were on a real life, maybe what the patient needs, It was to increase. I, I think the other thing to think about is when the x-ray was taken and how much throughout the day the patient still has to stool. So, this is the if then game we play when we review x-rays. That patient may have 12 hours left in the day to have another very large stool. So, if they did, then that rectum may be much cleaner and so you may not have to adjust as much. So, you got to kind of keep in mind the timing of the x-ray. In the portion of the 24 hours, so sometimes we always have this meeting with all the doctors and all the nurses and sometimes the nurses tell after this X-ray the patient had a large bowel movement so we have to in our minds think that well maybe that stool that we are seeing is already gone and that's how we we play on the decisions on what to do. So, uh, that's it. You're, OK. So here's what I'd, I would like to do is we have about 8 minutes left. Maybe we can go a few minutes over, but, I want to take this time for anyone to get off their chest, anything they've wanted to talk about, uh, especially the, the, the virtual faculty. Um, you know, we, we ended here on laxatives, but going back through the day, if anyone has comments or points they want to make or questions about what's been discussed, things they've disagreed with, we'd like to get that out there. And, uh, let me, Michael, you've been the one who's had the most to say today, so let me go to you first. Is there any Uh, things you want to get out there, points you want to make before we conclude the session today. Well, yeah, I just had a couple of quick things. First of all, because I'm a father of, uh, children with special developmental needs, I just wanted to say that these kind of same things can work in kids like with Down syndrome and other syndromic things, but sometimes you have to wait till they're a little bit more mature and until they have the, um, The investment in keeping clean because it's difficult sometimes to do these things in children who have developmental challenges, and if you try to do too many things too soon, you'll end up sometimes blocking your success. The other quick thing I wanted to say was that That the MiraLax use is a subject when we go to pull through network meetings, a lot of kids are there being managed on MiraLax, and, as, as other people have said, they tend to have problems with continence. They get more frequent stools, so just be careful about using MiraLax in kids after that and then. And then the other final thing I wanted to say about technology is if you have pictures of surgical reconstructions like this, be careful about sending them to Dr. Pena because the last time I tried to do it, my McAfee system blocked and said I had objectionable content to my mail, and I had to call my IT person to make sure I wasn't on some federal list of an inappropriate thing. I'd say that kind of tongue in cheek, but it's a true story. OK, thank you very much. Uh, let's see, uh, Ramon, do you have any comments to make? Well, we are very happy to introduce the, the this the program in Spain because it's not, uh, they, they don't do it before and it has good results, but we have the problem with the, the Senna because it's not recommended for, for the young kids because they think that it, it causes a cathartic colon or something like that, but we are using it. We have no, no second, uh, I mean, effects, and we are very, very happy with that. OK, um, Stephanie. Uh, hi. Well, I was very happy to share all the experiences. I just want to uh add one thing. Um, what we're doing actually at the moment is that we are doing seminars for kids in, in just before their teens. So that they learn very early before they come into puberty to administer the enema by themselves and I think this is a good thing and this is just something I wanted, you know, to mention to draw everybody's attention to. I think we have to respect. The privacy of the kids when they become older and so before they go into puberty, they should learn to administer the enema. So you know you brought up a point that I want to talk about is that a lot of families have approached us as well and we have this great medium now where we can all talk together. In the world, but it would be great to bring the same group together to have one that's dedicated to the patients' families, and not just clinicians to go over all the things that we've been discussing and answer their questions in this open forum where they get not just one opinion but they get 25 opinions. It may confuse them a little bit, but it, it, it's something that we should consider, uh, as we move forward. Um, let's see who's Ernesto. Yes, thank you very much. Um, I personally, it was very nice and especially when we discussed about the bowel management, and I think that these type of things, we have to start as soon as possible. In our center we start since the time we closed the colostomy, and that makes life easier when the child is growing up because he's getting used to these protocols. And also the result seems to be better, but we will present probably later in the future. Thank you. Thank you. Um, I'm going to say a comment and then we're going to go down and just say some closing remarks. Um, this is completely off label, and I'm going to make sure I say that first, but, uh, and I have absolutely no data to substantiate this. But I have been doing gastric electrical stimulation for gastric dysmotility, for gastroparesis, and, uh, for some reason, we've been seeing that these patients have been having more frequent stools. Uh, we don't know why or how that happens. We know that it propagates peristalsis. It may be a neurofeedback loop. We don't know why and it doesn't happen in patients that necessarily have colonic dysmotility. But we are beginning a study in animals and in a human trial to understand the effects of gastric electrical stimulation or sacral stimulation, which we know works for incontinence called uh InterStim, but it would be interesting to see if this would also work for constipation. So, hopefully in a few years, I'll have some data to present. But as we listen to all these novel therapies, I think that, uh, what we're learning is that these patients are all very different. They don't, it's not one group, and we have to figure out how to treat them all differently depending on what the cause is. Monica, thank you for joining us today. Um, I think this was good for us to learn that we frequently have mostly physicians up here, but I think we realized how valuable it is to have a nursing perspective on here. Uh, I know I rely almost entirely on my nurse for this, uh, area and, and your input's been great. Do you have any last minute comments that you want to make? Uh, thank you for inviting me. Um, I think if you have the ability, one of the best things for success in the bowel management, um, is having a. Uh, primary nursing or a patient nurse because the relationship that you build that way is so beneficial to their success, um because it can be very frustrating for them and for them to understand that this is constant changing and ongoing that the regimen you picked today may need to be adjusted along the way and that they should um always reach back out to you and not get frustrated so you can help them get back on track but I think. If you have the ability to have that same contact person, then that is great support for them and builds their success. I think that's a key point. And uh if you could, I asked you once before, maybe if you could do it again, put the web address that people could contact you. I think you'll probably get a lot of questions after the show about things. And Mark, do we have the capability for continued chat after this or not quite yet? Not quite yet on this page. We're working on that. That will come soon, um. Doctor Pena, any, uh, last minute comments? Thank you first of all for coming. So first of all, thank you, uh, to, to Todd Ponsky for the big effort. This is a, a very novel idea that, that, and this is just the beginning. I'm sure that in the coming years this type of communication will help many children and will. Um, allow us to keep in touch with our colleagues from all over the world, and we all learn one from each other. So thank you very much for your, your, uh, um, your innovation in the way of communication. And of course thank you for all the participants and to all the members of the audience. For me it's always an honor to be here. Thank you very much. Thank you for coming. Andrea, I just, again, I don't wanna be repetitive, but I just wanna thank everybody thank Todd for all the organization to make this event and thank you all the panelists for participating, for bringing their ideas. Uh, I think most of you know we do, uh, once a month we do a Colorectal web meeting we're gonna put in the global cast, uh, web page if you wanna join us, and we are super. Happy to have so many people interested in bowelmanagement because we are convinced that we can improve the quality of life of many children by doing something simple and it can be done anywhere in the world, so we're extremely proud to have so many people interested. Thank you for participating. Thank you, and I want to reemphasize that point. I don't know if there's a link for that, but we will put that on the bottom of our page if you come back in the next day or so. It will be at the bottom. Um, so that you can join these webcasts. I've heard, uh, Doctor de la Torre was telling me about these, uh, when we were overseas, and I think it's a great, uh, idea. And so we'll make sure that everyone here knows about how to get onto those events. Um, I think it would be helpful for everyone. And any question, you can always email us and we try our best to be answering all emails with questions, patients, discussion, anything. We'll be happy to help. Thank you very much and again. Big thanks for taking the time to come here. Thanks to all the faculty. Uh, some of you are up in the middle of the night, and I appreciate you being there and staying awake with us. I know that the audience is, uh, all over the world, so thank you. Uh, just, uh, I wanna just make two points. One is I want to tell you what's coming up soon, but, uh, every time those of you who follow these regularly, you know that each time we try some new technology. To try to advance us further. We've tried this big step today which was trying to push this into a high definition feed, more like a television show rather than a webinar, and uh we, we have some minor quirks to work out that hopefully will be fixed by, by the next show and uh we'll, we'll let's stay tuned and we'll let you know how the new software is working out. I want to tell everyone about one show that's coming up. It is a very important thing and I want everyone to know it's a trial, and I'm not sure how it's going to work. I don't want just one place deciding this curriculum. I want the world deciding this curriculum. This is becoming a great opportunity for us to come together. And so what we're doing now is we're starting a series called Maintenance of Certification or basically a pediatric surgery update symposium. And, and how we're doing this is we're inviting centers around the world to help participate in this curriculum, to help decide what we should be teaching, what we should be talking about, to start standardizing what we're teaching around the world. Uh, I want to mention that the very first one we're doing, the idea is after about 2 years, we will have gone over most of the curriculum and this will rotate every 2 years. We want to bring in hospitals from all over the world to rotate in to be faculty to present from their institutions so everyone in the world can now be a part of the curriculum. Cincinnati Children's, um. Uh, uh, Children's Hospital of Philadelphia, Children's National Medical Center, Toronto Sick Kids, um, uh, Mercy Hospital for Children, Long Island Jewish, and I'm sure I'm forgetting others, uh, and Akron Children's Hospital are the core group for this first event, which is going to be September 18th. The idea is it will be case-based presentations, no lectures, just talking about a case and Stopping and asking everyone around the world what would you do next, and we're going to do this with all the different areas in pediatric surgery about every 6 months. So we invite you to join on September 18th to this uh curriculum, this maintenance of certification series, and, uh, for now, I want to thank everyone in the studio here, the, the, the, the number, huge number of people that we have working in the back room that you can't see that put this together. And I want to thank our in-studio faculty, our virtual faculty, and all of you for sticking around and being loyal followers of these, uh, symposiums. Thank you very much. Have a good morning, good afternoon, and good evening.