Bowel Management - Use Of Ultrasound To Monitor Effects Of Enema

So thank you for the opportunity to talk a bit about one of my hobbies, which is hydrocolonic phonography. We use this method to, um, our philosophy is, well, on the one side, to not to not to make a guess what the amount of the enema should be, and on the other hand, to avoid radiography. Could I have the next slide, please? Sure. So the indication for hydrocolonic sonography is on the one hand, fecal incontinence. With hydrocolonic sonography, I will try to show you that later. It is possible to evaluate colonic motility and to measure the volume of the enema needed. So, um, we try to save some time to tailor the individual enema for the patient. Next slide please. Could I put, yeah, so, um. I think it, yeah. The other indication is constipation because in constipation you we can see the fecal impaction and so once again we have the opportunity to evaluate colonic modality and to identify stool infection and once again the aim of the whole procedure is to tailor the individual enema. So, um, the first step in the diagnostic process is to do, um, pediatric surgical evaluation of the patient, which means a detailed clinical history, a good physical examination. In many cases we do need to do an exact classification of the. Malformation because we're sort of a reference reference center and in many cases, especially in older patients, we do not know the exact classification of the malformation and it's sometimes you feel a bit like a detective to find out what the patient originally had. Then, uh, we do a detailed evaluation and look for associated defects, and patients are requested to fulfill a two-week defecation protocol prior to, uh, the therapy. Well, um, the point why we do this, uh, protocol is that uh we try to make two different groups. Um, the one group is we, we talked a lot about the pseudo incontinence and overflow with intact continent organ today, so. Um, this is the one group and the other group is the, uh, those are the patients soiling as a symptom of true fecal incontinence due to incontinence of the conti uh uh incontinence of the continent organ. So, um, the treatment protocol is orientated, um, according to the diagnosis that we find. We always start with intestinal purgation with polyethylelucol. This is macrogal or moviol because you need a clean colon. We've talked a lot about cleaning the colon today already, um, for the evaluation. So this is to start and get the right orientation for hydrocolonic sonography. After the hydrocolonic sonography, we put our bowel management program together. We're trying to get an individually tailored enema. One other step of the program is anal hygiene, which means patients are told to. Do to shower after every enema, we recommend physiotherapy, and patients are requested to have a defecation protocol so that we can monitor whether we are successful with our enema or not. And in many cases we recommend a psychiatric workup to find out whether patients have additional problems. So what do we do for the for the for the hydrocolonic sonography? We have two different systems that you can use. You can either use an electric pump system. This is a pump that has been evaluated for it usually was used for irrigation of stoma, and this is another pump that is a hand pump that was made for people with spina bifida, and you can use that for hydrocolonic sonography as well. So the next thing you have to do is you have to find the perfect catheter for the patient because if you don't have the perfect catheter, your whole sonography won't work. There are different kinds of catheters with this system. There is a catheter that goes with the system, and it has a very big balloon. So especially in patients with, in older patients with a not intact continent organ, this big balloon is very helpful. Um, with the electric pump, there is no perfect catheter included, so we are using the same catheter system as you do in Cincinnati. We're using a Foley catheter, 24 Cherie with a blockage of 30 mL. So what are the ingredients needed for hydrocolonic sonography? You need the irrigation pump, you need the catheter, you need a syringe, and you need a system to connect everything. Um, Then then you put the system together, you connect all the different parts. Um, if you've done that, the method is the same as in Cincinnati that you put the syringe, uh, on the Foley catheter to block the balloon. One thing is very important. If you want to do successful sonography, there should be no air in the colon. Everybody who does sonography knows it is very difficult to monitor the abdomen because of the air. So we do the purgation to prepare the colon, and then when we fill the colon, we should be really sure that at that point, we don't put any air in. So you should clear the catheter of any air. Um, another point which is very important and has been stressed before is explanation and cooperation of the kids. So what you see here on the slide is the hand of a little boy, and we explain to him why we inflate the catheter. We fist is your anal opening. We put the catheter. In we we inflate the balloon, and now you can see that your anal canal will be closed with a catheter and you can feel that the inflated balloon does not hurt you. And then we put the material on the abdomen and we usually try to make some funny faces so the kids feel fine. Hydrocolonic sonography is done in a special room. It is usually a procedure that is done in the presence of the parents. This we specially made these pictures. So this is one of my kids, and I made the pictures just to show you how we do it. So the parent is in the room, although, the parent is the investigator at this point. So, um, the kids are told that they, they should watch the, uh, a, the, the water progress on the ultrasound. And what exactly we're seeing, I want to show you now. So, if you clean the colon successfully, what you see is this lovely movement, and you can really make contact to every colonic cell, and you really feel like you're part of the colon. So, I really love that part. So I'll show you that video once again. So you can see the movement of the colon. Um, you can measure the time between filling the colon and the first movement, the adaptation period we call it. And, uh, on the next picture, you see that the kid was not perfectly clean at this point. The, um, there are still some bubbles, the, the white spots, uh, that is air bubbles, and you can see that, um, he's not totally clean. So, what we try to do with, um, With the hydrocolonic sonographer is we want to monitor whether we reach the cecum, and this is the cecum, and here you see that our enema has reached the cecum. So if the volume of the enema, if we have reached this point, we measure the volume we have needed, and so So the idea is that now we are in the cecum and then we can compete with the Malone antegrad enema because if we have a volume of liquid that goes up to the cecum, we should be as good at cleaning the whole colon as with an antigrat enema. Um, next slide, please. Um, I told you before, one of the other aspects is that you can try to see fecal impaction. No, wrong direction. OK, that you can also see fecal impaction, which is, which is very important in children with chronic constipation, so that you can see a big fecal, um, a fecal stone in the rectum here, and then you know that this child has a severe constipation problem. After the enema, the child should go to the, after the hydrocolonic oscopy, the child needs a toilet, and we do discuss with the parents what in our eyes the perfect toilet is, and that would rather be a toilet where you sit low and your feet are firmly fixed on the ground. Well, um, as you, um, Monica said before, it is not always easy to keep the child on the toilet for a long time. So this is a very, um, a motor, um, a toilet model from roto router. You can really order these ones, but, um, that might be a bit too much. So just to give you a short overview of 20 patients, those were all grown-ups that came at the age of 14 plus years to us, and they were told that they were fecally incontinent after anorectal malformations that had been operated on some even more than 20 or 30 years ago. All of the patients learned to To control, uh, well, this is before treatment. All of them had constantly social problems and they were constantly soiling. So they went into the, um, hydrosonography and, um, received a tailored enema and we reevaluated the. patients after 6 and 12 months and it was really a very um positive result. Only 2 patients still had problems with incontinence and soiling, and those two patients were the ones that did not follow our regime and had decided not to do any more rectal irrigation. So, um, in our eyes, hydro. Yes. Go ahead. Uh, I think, uh, I think Stephanie lost computer access because her camera and her phone went down. Uh, so cameras we still see her camera. OK. Oh, yeah, her camera's going, but not her audio. I think she probably lost her phone line again. on the phone. Yeah. So, uh, Stephanie, I don't know. It sounds like, I don't know if she can hear me, uh, but, uh, we're gonna, we're going to move on. I think that was her last slide anyways. She had one more slide that was, there is the conclusion. So, uh, I think she can't hear us right now, but basically, I think that that was, uh, very interesting technique, and I don't know, I know we're, we, we're gonna go to Doctor Nurko now and actually, if you can, uh, open your camera, Doctor Nurko, so we can.