The Colorectal Quiz Episode 7: Bowel Management Part 2

Hey there, listeners. This is Rod from Cincinnati Children's. Have you downloaded the new version of the Stay Current Pediatric Surgery app? It's in the Apple App Store, Google Play Store. The reason I bring it up is because if you're listening to this podcast in the app, then you'll be able to look at images, X-rays, in real time, while Dr. Levitt and Dr. Frisher are talking about them. So download the app. I know you're going to enjoy your time there, but until then, enjoy the episode. Last week, we talked about the key components of bowel management for a patient who had a PSARP for an anorectal malformation. So this week, kind of in the same vein, we're going to talk about bowel management for a patient who had a pull-through for Hirschprung's. To do that, Dr. Levitt and Dr. Frisher brought in a couple friends, two nurse practitioners with years of experience helping patients gain control of their bowels postoperatively. And in doing so, gaining control of their lives. So enjoy this episode of the Colorectal Quiz. Again, blessed with our nursing colleagues, Monica Huder from Cincinnati, Katie Worst from Children's National. That was Dr. Mark Levitt. He's a pediatric colorectal surgeon at Children's National Hospital in Washington DC. Jason, you want to present the case? Sure. Welcome back, everyone. And that's his partner in crime, Dr. Jason Frisher from Cincinnati Children's Hospital. This week, we have a 7-year-old male with Hirschprung's disease, and he presented to our office with constipation and fecal incontinence. So, for this patient's history, at 1 and a half years, had a rectal biopsy and myomectomy. 2 weeks after that, had a sigmoid loop colostomy. 6 months after that, so at the age of 2 years, had a Suave pull through through an abdominal perineal approach. And then he presented to our center after having undergone those treatments elsewhere, uh, with fecal incontinence, constipation, in second grade, and really struggling. So when we have a Hirschprung's kids come into our center, Katie Worst. We want to work the patient up so that we can better understand their anatomy and make sure that their prior surgeries were done well. And what she means is, keep in mind that this patient had their surgeries done at an outside hospital. So we'll start with an exam under anesthesia. If you can see here, we have a child with a patulous anus. If you're in the stay current app, scroll down under the media player and we have the images from the exam under anesthesia. Open them up and here's Dr. Frisher explaining them. Some rectal, little rectal prolapse, and probably greater than 75% of the anal canal, uh, missing or injured on the pull through procedure. So maybe a little bit on from about the 1:00 to maybe 4:00 or 5:00 position. There is some potential borderline anal canal, but the remaining area of the anal canal has been um, resected during the procedure and and the pull through has been brought out basically to the anoderm. And then the key questions, similar to the ARM is, does he have the anatomy required to have bowel control? And in patients with Hirschsprung's, that comes down to two factors. The first one, sphincters that contract. And the second one is a dentate line that can detect solid liquid gas. And this patient is deficient in both of these anatomic areas. So I would be very concerned about his ultimate potential to achieve bowel control and I would probably go with a mechanical method to get him empty. IE enemas or potentially integrate like a Malone. And the hope is that someday down the road, this patient may develop the ability to hold the anus closed and have control over the bowel movements. But what else did we have to do in the workup? I think it's also important with Hirschprung's disease to find out if the patient has been um suffering with any symptoms of um enterocolitis. Monica Holder. Versus having a little bit more time to work up a patient who is having constipation and incontinence but not in a urgent setting of an enterocolitis type picture. Okay, how about imaging? We'll set the patient up for a contrast enema. And wouldn't you know it, we have a contrast enema for you to look at. So scroll down under the media player. Open up that image. We have that and a scout film. You can see the hustral markings all the way down to the anus. By the way, we talked about this in in a previous podcast, if you ever see this image in an ARM patient, it means the surgeon removed the rectum. We talked about how important it is to preserve a rectum. In Hirschprung's disease, the rectum is part of the surgery for sure and usually the sigmoid as well. So this hyperperistalsis that you see is pretty typical. What doesn't go with that picture a little bit is the fact that the colon is still full of form stool. And this is a patient at this point in time, not receiving any treatment. But we did initially con really consider a hypermotile colon in this situation. Now, the image all the way on the right, the final image is the X-ray performed the day after the contrast enema. So 24 hours later, we had a plain abdominal X-ray. Monica, do you want to comment? Since it's 24 hours later and there's still a pretty good amount of contrast still left in the bowel, um, it would make me feel like it is not quite as hyper as maybe we might have first thought. Um, if it was really hyper, I think the the contrast would be cleared out almost completely, if not completely, in 24 hours. So, with that image maybe a little bit less likely leaning toward hyper, um, and considering maybe a little bit more needs of um, you know, hyper hypomotile management of some sort. Because think about it, if they were hypermotile, then 24 hours after all that contrast in that image should be gone. How should we counsel this family? I always tend to lean towards enemas, especially when we are talking about kids around this age. I think once they've gotten to the point around potty training age that they or they hope to be potty trained and they probably never have been clean. Um, I always think that enemas are a good idea to give them that temporary period of respite where we can clean the colon and keep them clean. Katie goes on to explain that if the child is leaking between the enemas, then they may need some sort of bulking agents or a constipating diet. The goal being, we want them clean for 24 hours between those times that the parent is giving the enemas. Okay, so Monica, what did we do with this patient? So we started on a um rectal enema. And do you want to describe what the basic ingredients solutions we use? So, unfortunately, there's no magic formula. The basis of our enema is normal saline, um, with some additives, some component of uh glycerin. And that could be in 10 mls to 30 mls. Sometimes we use Castile soap. These come in little 9 ml packets and you can use like one to three. Uh, we start kind of at a moderate to low amount and then increase either up or down as we need, depending on how well that combination cleans the bowel. And then you got to figure you're going to mix all that into saline, but how much saline are you going to use? That can vary depending on the patient. So go back to the contrast enema, find out how much contrast they used, and assume that that's the volume for their entire colon. Divide that by three, because we're not really going to try and clear out the whole colon every time with an enema. That's going to be your starting amount of normal saline and then you can adjust that from there. He's emptying well with the enema but had two accidents about 12 hours later, um, after the enema was administered. So he's not perfectly clean yet. The X-rays is still showing some stool burden. He's talking about that series of X-rays Monday through Thursday under the media player. We're probably going to need to I would go up on your irritant to begin with, um, or as my first step. Um, I also warn families that sometimes it just takes it's also going to get better with time. When you have patients here and in your clinic setting and for for a good week where you're going to see them at subsequent visits, I'd rather be more aggressive than less aggressive and and make sure that they're going to be really well cleaned out with an enema. But I also warn families that sometimes we can overstep because right now we're fighting much more than 24 hours of stool and the goal is to get an enema that's going to combat 24 hours of stool. We overshoot, um, and then a week or two later the kids actually is doing better and we're able to come back down on the irritant a little. So what if the patient has an enormous amount of stool burden at the beginning and we want to clear that out first. Here's Monica. We might disimpact the patient, um, until we do see a less burden of stoolled before we start to go to a once a day enema. We might do a couple enemas in one in a single day to really overcome that amount of stool load before starting on a once a day enema. Now, you may be thinking to yourself, is this like too many enemas? Well, that's a conversation to have with the parents. I think it's a very important at first meeting or first few meetings that you get the trust of the family. And to get the trust of the family, they usually want to see success. And being aggressive with enemas, at least for a short period of time is I think helpful in the long-term goal in treatment. So how do we build rapport with the parents and show them the importance of all of these enemas? Making it a little bit more normal and comparing it to maybe another condition that needs a daily shot or something like that so that they can perceive that this really is a daily treatment. I love that analogy. Think of it as a daily treatment like a patient with diabetes who needs insulin every day. That's what we're trying to convey. And then you got to address the social things. I also often times bring up just the patient's quality of life with these patient with this patient population and this young child is 7 years old, little boy who's probably around his friends and going to school and having accidents at unpredictable times. You can change that and give him once a day where you know he's going to have that bowel moment and then keep him clean. I mean it's life-changing. And that's why we're doing this in the first place, right? We want to change these patients' lives. Now, let's go back to the X-ray. You see how there's a little bit of stool left behind in that second image. So how do you counsel a patient and a family on that? Yeah, so um, that's actually the number one thing to figure out when you're giving the enema is, is making sure the patient is retaining it because no matter what you do and what combination you give, if the patient's not retaining it, then nothing's going to work. So what they do is they actually special order a 24 French foley catheter with a 30 ml balloon. Um, and what we have them do is after inserting the foley catheter, blowing up the balloon, um, to create a plug, because remember that this patient doesn't have those sphincter muscles anymore, so the balloon kind of acts like the muscles. Um, and it is important that as the enema is going in, sometimes you need to hold tension on that catheter so that the balloon doesn't kind of float away in this bowel that's getting filled up with um water. One question that does come up a lot, um, is, you know, what do you do about the patient that will not tolerate a rectal enema? Is it is it okay to give them an integrate option even though you have not succeeded yet in a bowel management regimen? Yes, it's invasive to insert a catheter into a child's rectum on a daily or semi-daily basis, uh, to perform the enema, but many children are also fearful of a catheter going into their abdominal wall. The actual process is the same. It's just where is the solution being entered. Our typical pattern is certainly rectal enemas first because I'd also hate to do an invasive operation with still a poor outcome. And I think also understanding it's not the Malone that is curing the overall quality of life. Surgically placing them alone in the abdomen doesn't fix it. So being sure that whoever is offering that if appropriate has the ability or the desire to make the enema solution changes that is needed to get to the ultimate end goal is having the kiddo clean in the underwear free of constipation and symptoms. But no matter how much you do to explain to the parents, don't forget that you also have to convince that kid in your office. A little girl about 7 years old came to our bowel management program and said, and I said to her, you're here because we are going to make you clean and dry for urine and stool and you can wear normal underwear. And she looked at me and said, basically with her eyes, as seven-year-olds tend to do, that I was crazy, that I was an an adult that couldn't possibly have any understanding of what's going on in her life and could possibly deliver that for her. And after a week of bowel management, she came into clinic and looked me in the eye and said, Dr. Levitt, you make really good promises. Oh my goodness, that hits you right in the heart. Who's who's cutting onions in here? Stop. I I need something to like make me laugh now. There were they were two wind turbines in one of these wind farms. And they were talking to each other. And one asked the other, what kind of music do you like? And the other one said, isn't it obvious? I'm a huge heavy metal fan. Oh. Oh, the problems we have. All right, how about yours? Two flies walk into a bar. One fly says to the other, is this stool taken? Oh, gross. Phenomenal, perfectly appropriate. All right, let's summarize with some take home points. Number one, you need to start with a clean colon. Number two, you got to figure out the speed of that colon. Hypomotile or slow moving or hypermotile and quick moving, because that's going to determine the bowel regimen. Are you trying to slow them down or are you trying to speed them up? And then number three, you got to figure out the potential for bowel control in this patient. Whether it's an anorectal malformation patient or a Hirschprung's patient, determining whether their capabilities, whether it's their nerves or sphincter, will they have a good chance for bowel control? Because that's going to determine whether they're going to do enemas or laxatives or maybe one and the other. Number four, you need to make a plan. And they have to be consistent taking the medication and have a consistent regimented plan uh for every day. And then the last part, it's okay to be flexible. We're always willing to try a different treatment plan if that is what's going to make your quality of life better, because in the end, I think we all feel that the point of bowel management is to make the quality of life for the family and the patient better. Thanks, Rod. No, thank you, Dr. Frisher. And thank all of you for listening. I mean, these episodes shed a lot of light on the fact that the care for these patients doesn't just end at the operating room. There's so much that goes on in the clinic in the postoperative period. Dr. Frisher and Dr. Levitt are lucky that they have such amazing teams at Cincinnati and Washington DC. But what about your team? Do you want to tell us about something you do differently or maybe it's the same? Well, you can find us on social media or if you're in the stay current app, you could just comment on the podcast in the app. Pediatric surgeons around the world can see it, interact with it, and start a discussion right there. So download the app. It's in the Apple App Store, it's in the Google Play Store. I'm Rod Gerardo from Cincinnati Children's and remember, knowledge should be free.