The Colorectal Quiz Episode 6: Bowel Management Part 1

Hey there listeners, have you downloaded the new version of the Stay Current app? We got a brand new layout, new features and content, but the reason I bring it up here is because if you're listening to the colorectal quiz in the app, then when Dr. Levitt and Dr. Frisher talk about images, you can open it up and look at the images while they're talking about them in real time. So check it out. It's in the Apple App Store, it's in the Google Play Store. But until then, enjoy the episode. All right, welcome back everyone to the Colorectal Quizzes. That's Dr. Jason Frisher. He's a pediatric colorectal surgeon at Cincinnati Children's Hospital. We have decided to go a little bit off the surgical path. No, no, no, don't close the podcast just yet. Surgery is only one portion of the whole picture of taking care of a colorectal patient. And this episode is about the care they get outside the OR, bowel management. I'm lucky enough to have invited Monica Holder, a nurse at the Colorectal Center here at Cincinnati Children's. And she's been there for over 15 years. Making her slightly experienced in this field. Dr. Mark Levit out at Children's National Hospital also brought a friend. Her name is Katie Worst. Who was a nurse practitioner who runs our bowel management program and is an unbelievably wonderful colleague. Operation for colorectal problems takes about four hours, but to get a good result takes about 96 hours of good solid work. And much of that is nursing care. They both agreed that we're better surgeons because of the care that our nurses provide to our patients outside of the OR. So let's jump into the first case. Five-year-old girl born with an anorectal malformation and a recto vestibular fistula. She presents to clinic with soiling. We're going to kick it off with Katie. Knowing that she's a five-year-old with anorectal malformation and recto vestibular fistula is great, but if we want to be able to give a good potential predictor to the family, we're going to need a little bit more information. If you've been listening to the other podcasts, then remember that there are three things we look at to help figure out the potential for bowel control in these patients. One is the type of malformation that the patient has. And this is a rectovestibular fistula, which is a lower lying fistula, which gives her better potential for continence. Because remember the higher ones have sometimes a worse prognosis for bowel control in the future. And those are high prostatic bladder neck or cloacas with long common channels. Okay, number two. Her spine and whether or not she has a normal spine, or is there a persistent tethered cord? And then number three. And then we also want to take a good look at her sacrum and try to good at uh her sacral ratios will also give us a better indicator as how good her potential for continence in the future will be. Then Dr. Frisher brought up something that we forgot to mention from the jump, where we're under the assumption that there's not a stricture or any other anatomic problems or significant prolapse, etc. So, so remember that for this specific podcast, we're not talking about surgical complications or any anatomical issues. We just want to focus on the patients who are totally set up from every other aspect and now we just want to focus on their bowel control. Let's assume for argument's sake that this patient has had a very nice repair, very impressively done anoplasty anatomically correct. And yet, they are still soiling. So Monica, how would you handle that? Jason comes out of the OR tells you, the EUA on this patient that was referred from somewhere else is perfect, the surgeon did a great job, but we have a five-year-old that's soiling. What should we do? Obviously, the goal of this family is for their child to be clean in underwear. And at five years old, the other kids around her are probably starting to get clean in their underwear, so it makes it more apparent. So what's the most important thing to tell the parents at this initial visit? I think it's important to understand that you will likely not get control of the soiling and constipation until we start with a clean bowel and start from scratch. So typically part of that workup is a contrast enema. And I know we're not using barium, so what are we using? Um, so we like to use a water soluble hypaque contrast. And that gives you sort of a road map of how the colon looks right now. The other reason that they like to get the contrast enema. We do get a scout image with that contrast enema, so we can see the level of constipation, um, at a everyday standpoint for this patient. Now, kind of intuitive, but don't do a clear out of the patient before you get this contrast enema. Now, don't worry though, because the contrast enema is good for getting all these images and everything. And it also secondarily because it's laxative in nature will help the bowel clean out and empty so you can start whatever bowel management regimen you're going to go to next on a clean colon, um that we do confirm with x-ray after the contrast study. Dr. Frisher thought it might be a good idea to define some obvious terms. What is bowel management? And Monica, Katie, I want to hear from both of you because I think we use this very big umbrella term bowel management. Bowel management is basically a generic term to um say we are going to come up with some regimen, um that we are going to use on a consistent basis to help treat your symptoms, um whether that is constipation, whether that's fecal incontinence, whatever that child presents with, um and those therapies can be different, um and should be different depending on the patient's needs and scenario. So there's a wide range of treatment options when it comes to bowel management from medications like loperamide to dietary changes, physical therapy, sometimes enemas, but it all is based on the goals of the family. Um so it's basically just a combination of therapies that gets to the goal of being clean in the underwear and symptom free of any abdominal pain, distension or the typical signs you see with constipation. Now, where were we? Um, oh, the imaging, right? So, let's show that. Uh I we have um the scout and the contrast study for this particular patient. And if you're listening to this in the Stay Current app, you got it too. So scroll down under the media player, open up that first image. We didn't talk about the sacrum or spine, but let's take both scenarios. In one scenario, good sacral ratio, 0.8, normal spine. And then another situation where the patient has a poor sacral ratio, less than 0.4, and then a tethered cord. So the images that we're looking at the scout film or the x-ray, it looks pretty well full of stool. Um and then the contrast enema shows a pretty dilated like recto sigmoid colon. Now, patients are usually broken down into one of two categories. Hyperperistaltic colon or a hypo peristaltic colon. Now, here's Katie's thoughts. Based on the imaging and the fact that the colon is so dilated and yet also that full of stool, I would expect that this patient is probably more hypo modal and that she's not cleaning or fully emptying her bowels on a regular basis. And then when she is, she's ha or the incontinence that she's having, the soiling that she's having is probably some of um some stool seeping around hard and accumulated stool that remains in the colon. So, I think regardless of whether or not she has good or poor potential for continence long-term, in the immediate future, if this patient presented to me in a clinic, I would I would talk to the family about starting rectal enemas. She goes on to explain that patients with this kind of imaging and story are probably chronically constipated. So when their rectum is that dilated all the time, sometimes the signals that go back and forth between the intestines and the brain to say, hey, it's time to empty your colon, they're either ignored or they're just kind of untrained. So, if we start with rectal enemas, I think there's a good chance that we can help retrain her colon to understand what it feels like to be empty. Then after a period of, let's say, six to 12 months, the patient with the better prognosis will probably be able to transition to laxatives. Now, the other patient who had the tethered cord and the poor sacral ratio, they may not transition so easily, but Katie was quick to say that we're always willing to try if the family and the patient are up for it. But you got to set their expectations. I do likegrade as a bridge to continence. I have found that if you do an grade um option like a Malone, and my preference is a is a Malone overstomy. The patient can practice holding in the flush. And if they can hold in that flush, which is liquid, and release that flush when they choose to, basically they have bowel control. But that process might take six to 12 months depending on the patient, but definitely worth a try. I think the other point to be made is we don't use the term laxatives lightly. That means that they're not getting stool softeners. They are getting laxatives and they don't have the best sphincters. Remember, all of this was created by the surgeon during the repair. They are completely dependent on the fullness, on the proprioception that you get by having a rectum filled with stool. If you give a patient like that a stool softener like Miralax, you eliminate their ability to feel fullness in the rectum and you make the patient worse. However, if you give them bulk with high fiber, a water soluble fiber and kick out the stool with a stimulant laxative like Senna, they can have one formed stool per day and that is their best shot at having bowel control. Dr. Frisher was quick to point out, if you're that surgeon who's having a lot of trouble controlling this patient's constipation and you go back in, don't resect that recto sigmoid junction, you're going to lose the proprioception that Dr. Levit's talking about. And then you go the other end of the spectrum, they end up being incontinent. So, here's what Dr. Frisher does sometimes instead. Is I've tapered the recta mega recto sigmoid when we really have problems emptying it, but to resect that entire mega recto sigmoid, you could get yourself in some trouble. Monica brought up a good point that this patient we're talking about is five years old, so still pretty close to like potty training age, but keep in mind that the surgery happened years ago. The constipation can start very, very, very early on and so not ignoring the constipation treatment needs, um, you know, directly after surgery or shortly after surgery to prevent all of this dilation and stretching of the colon, um, that's happening from surgical date to potty training date and so you could potentially prevent some of these um complications that happen later with the pseudo incontinence. Oh, well, you know, me as a surgery resident, I thought we just close up the skin and say, well, we're done, see you, have a nice life. But sounds like there's more to it after the surgery is done. So we check in with our patients fairly regularly even immediately after surgery. I mean, most of our patients will go home on some type of medication regimen to keep the stool soft, immediately after immediately after surgery. And then at about a month, we'll try to switch them to a low dose of laxative from the getgo. Um, and then after that they check in with us every, I don't know, month or two months. Um, but for sure we have told all of them if for some reason they don't stool for 24 hours, they're to let us know. Yeah, I think that's a great point and I think many of us know that when we do a colostomy closure after recto malformation reconstruction, often the first few days to a couple weeks, the stools are loose and you're dealing with diaper rash and then there's that conversion, that moment where they start passing clay like stool and and hard formed pebbles and and you got to jump on that and be aggressive and uh try to prevent the chronic constipation and uh morbidity associated with that afterwards. So really that education it happens like in the hospital at the time of the colostomy closure. So we educate the families extensively on what to look for. And that post-operative education is invaluable. You have to empower these parents to know what's normal, what's not normal, what to expect. And when they should probably call Monica or Katie. Surgeons like us would be lost without them. And here is Dr. Levit's final thoughts. So that was great evaluation of an anorectal malformation patient and the bowel management strategy are unique and we talked about the uniqueness of the rectum etc, but boy, do we have challenges with Hershrungs. I always love talking about Hershrungs and you're right. Unfortunately, we ran out of time on this podcast. But we should probably end this session with a joke. Well, I was just curious if you knew a reason and I think there is a reason why it's obvious that Elmo is always male. I don't know, you stumped me. Well, before they leave the factory, every one of those Elmos gets two test tickles. That's terrible. Oh my god. Okay. Tickle me Elmo. Do you remember when, oh boy. Not to be outdone, here's Dr. Frisher. Did you hear about the constipated accountant? Didn't hear. He couldn't budget. Oh my goodness. It's terrible. Just it gets worse and worse. Thank you so much, Monica and Katie for granting us just a fraction of your endless wisdom on bowel management in the post-operative period for our patients. But they're not done. That was just part one. Tune in next week when we're going to talk about how there might be some different considerations when a patient has surgery for Hershrungs disease. Did you enjoy the episode? Were you listening on Apple, Stitcher, Spotify. That's great. But that means that you're missing out on content in the app. So download the Stay Current in Pediatric Surgery app and then when you listen to these podcasts, you'll get to see the images, you'll get to comment below and have a conversation with another pediatric surgeon. But until next time, I'm Rod from Cincinnati Children's and remember, knowledge should be free.