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OBJECTIVES: To determine whether the combination of laxative treatment and biofeedback therapy (BF) is more effective for management of functional nonretentive fecal soiling than biofeedback therapy alone. STUDY DESIGN: In a prospective nonblinded study, 48 children were randomized in 2 groups: treatment with oral laxatives (LAX) and 5 sessions of BF (BF + LAX) or 5 sessions of BF alone (BF) during a treatment intervention period of 7 weeks. Biofeedback was performed with perfused manometry catheters and rectal balloon distension. Training focused on awareness of balloon distension and instruction in correct defecation dynamics. Successful treatment was defined as <1 encopresis episode per 2 weeks. RESULTS: At the end of the intervention period, the number of encopresis episodes was significantly decreased in both groups: from 7 (2 to 24) to 2 (0 to 17) in the BF group and from 7 (3 to 25) to 2 (0 to 14) in the BF + LAX group. However, children given BF alone had significantly higher success rates than children treated with BF and additional oral laxatives (44% to 11%). CONCLUSIONS: There is no additional effect of laxative treatment in functional nonretentive fecal soiling. Children treated with BF in combination with laxatives showed a significantly lower success percentage compared with those treated with BF alone. These results suggest that children with functional nonretentive fecal soiling should be treated differently from children with constipation and encopresis.

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El estreñimiento crónico es un problema frecuente en la edad pediátrica. El 95 por ciento de los casos de estreñimiento crónico es funcional, es decir, no debido a causas orgánicas, anatómicas o por ingesta de alimentos. El estreñimiento debe ser distinguido de la enfermedad de Hirschsprung y de alteraciones anatómicas y metabólicas. La evaluación clínica incluye una historia clínica completa, el examen físico adecuado y paraclínicos como radiología, manometría anorrectal y biopsia rectal. El manejo incluye cambios en el medio ambiente, la dieta y los medicamentos. El propósito del presente artículo es proporcionar una orientación diagnóstica y terapéutica en niños con estriñimiento crónico funcional

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OBJECTIVE: To evaluate whether the ability to defecate a rectal balloon might predict 12-month recovery in children with functional constipation and encopresis. METHODS: We evaluated the ability to defecate within 5 minutes a 100 ml waterfilled rectal balloon by 20 healthy children and 139 children with functional constipation and encopresis. RESULTS: All healthy children and only 47% of the patients were able to defecate the balloon. Twelve months after the start of treatment, 51% of patients able to and 34% of patients unable to defecate the balloon had recovered (p < 0.03). Logistic regression revealed that the ability to defecate the balloon and a history of secondary encopresis were related to recovery (p < 0.04). Patients who were unable to defecate the balloon or who did not recover had significantly more impairment in anorectal functions than those who were able to defecate the balloon or who did recover. The ability of the balloon defecation test to predict recovery had a sensitivity of 57%, a specificity of 60%, a positive predictive value of 0.51, and a negative predictive value of 0.66. CONCLUSION: Children with functional constipation and encopresis who were able to defecate the rectal balloon were twice as likely to recover. Even though there was a clinically significant difference in the recovery rates between patients who could and those who could not defecate the balloon, calculation of predictive values showed that the balloon defecation test could not reliably predict recovery.

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Anorectal manometry is a non invasive, safe and useful procedure for exploring anorectal function in several disease. The anorectal studies made in our service the last five years in children, were reviewed. There were made 234 procedures in patients 21 year old or less 93.25% of the studies could be finished and 72.64% of the patients were from other hospitals or centers. The age average was 5.62 +/- 4.72 years and the main indication was constipation (78.20%). We didn't find any statistical difference in the manometrical findings of the internal anal sphincter between the patients with only constipation, only encopresis, constipation plus encopresis and normal values. The main manometrical diagnostic in the constipated patient without Hirschsprung disease was "Normal Study" even though between 30 and 55% of the studies showed "inspecific motor dysfunction". The patients with anorectal malformations had a main internal and pressure statistically lower (Z = 3.29 p = 0.03) and "Non concluyent Study" percentage higher (Z03.44 p = 0.02) than the constipated ones. The main external anal pressure was not different between groups. In 43 patients the manometrical study showed "Suggestive of Hirschsprung Disease". We recovered the histological reports in 55.88% with aganglionosis in the 91.66%. There were no statistical differences in the other manometrical parameters. Our finding agree with the ones reported in the specialized literature and support the anorectal manometry as an useful tool for exploring the anal sphincter integrity in anorectal malformations.

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We performed a rectal motility study in 39 children with encopresis and in 41 with chronic functional constipation. A three balloon system Schuster technic, was employed. Pressure changes were recorded. The "Inflation" reflex was absent in 23/39 children with Encopresis 59% and in 11/41. 26.8% with chronic functional constipation (p < 0.05).

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Se estudiaron 80 niños, 41 con constipación funcional crónica y 39 con encopresis que acudieron al servicio de Gastroenterología del Instituto Nacional de Pediatría (INP) durante el período comprendido de enero de 1993 a enero de 1994. A todos ellos se les efectuó estudio de motilidad anorectal mediante la técnica de Schuster de triple balón. La presión basal de reposo del esfincter interno en los niños constipados fue de 47.15 mm Hg. mientras que en los encopréticos fue de 59.56 mm Hg (P<0.0008). El reflejo recto anal inhibitorio estuvo presente en los 80 pacientes (p>0.05). En cuanto al reflejo de inflación o contracción éste se encontró ausente en 23/39 niños con encopresis (59 por ciento), mientras que estuvo ausente en 11/44 niños constipados (26.8 por ciento) (p<0.05). (AU)

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Se estudiaron 80 niños, 41 con constipación funcional crónica y 39 con encopresis que acudieron al servicio de Gastroenterología del Instituto Nacional de Pediatría (INP) durante el período comprendido de enero de 1993 a enero de 1994. A todos ellos se les efectuó estudio de motilidad anorectal mediante la técnica de Schuster de triple balón. La presión basal de reposo del esfincter interno en los niños constipados fue de 47.15 mm Hg. mientras que en los encopréticos fue de 59.56 mm Hg (P<0.0008). El reflejo recto anal inhibitorio estuvo presente en los 80 pacientes (p>0.05). En cuanto al reflejo de inflación o contracción éste se encontró ausente en 23/39 niños con encopresis (59 por ciento), mientras que estuvo ausente en 11/44 niños constipados (26.8 por ciento) (p<0.05).

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Children with encopresis (costiveness) have a social problem, and (BFB) offers them a valid therapeutic alternative. The present prospective study compares the advantages of this technique with conventional treatment in 21 patients, with average ages of 10.13 and 8.54 years in each group. The patients were studied by clinical, manometric and electromyographic parameters. Those treated with BFB showed clinical improvement, with manometric significant enhancement (p < 0.001) of the percentage of internal anal sphincter (IAE) relaxation, relaxation interval of the IAE and rectal sensation threshold (RST), on the other hand, patients treated by conventional therapy only improved the RST (p < 0.01). Biofeedback seems useful in the treatment of the child with encopresis.

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We studied the ability to defecate water-filled balloons in 16 healthy and 37 chronically constipated children with encopresis. The act of bearing down for defecation was evaluated by measuring intra-abdominal pressure, rectal pressure, anal pressure, external anal sphincter EMG activity, and rectal sensation and rectal volume necessary to inhibit the anal sphincters. Fifteen control children and 20 constipated children were able to defecate rectal balloons. External sphincter activity decreased during the act of bearing down for defecation in 100% of controls, in 58% of constipated children able to defecate balloons, and in only 7% of patients unable to defecate balloons. Constipated children unable to defecate balloons were significantly less likely to recover after conventional laxative treatment than constipated children able to defecate balloons (P less than 0.02). Increased external sphincter activity during defecation appears to be the factor that prevents balloon expulsion in constipated children and could be the cause of their chronic fecal retention.

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