Radionuclear transit to assess sites of delay in large bowel transit in children with chronic idiopathic constipation

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Abstract

Purpose

Chronic idiopathic constipation (CIC) with soiling in children may result from slow colonic transit (SCT) or anorectal dysfunction and/or psychological problems known as functional fecal retention (FFR). Evidence is accumulating that SCT and FFR need different treatments, but they are poorly distinguished by solid marker studies. The authors used radionuclear transit scintigraphy to categorize children with CIC as having either FFR or SCT.

Methods

Children (N = 101) with CIC (and soiling) who were referred for further investigation after failure of standard treatments (diet, laxatives) received radiolabeled colloid orally, and scintillation images were collected at 0 to 2, 6, 24, 30 and 48 hours (total radiation dosage = 2 standard x-rays). Radioactivity in 6 regions (precolonic, ascending, transverse, descending, rectosigmoid, and evacuated feces) was measured, and the median position (geometric center) of radioactivity at each time was determined.

Results

In children, meals normally reach the cecum at 6 hours and are evacuated in 30 to 58 hours. Fifty patients had retention of radioactivity in the proximal colon at 48 hours, indicating SCT. Analysis of the images and the geometric center showed that passage through the ascending colon and transverse colon was delayed in SCT. In 24 patients, radioactivity was passed by 30 hours, indicating normal transit or possible FFR. Twenty-two patients had retention in the rectum, indicating definite FFR. Five studies were borderline.

Conclusions

Radionuclear transit scintigraphy is useful for categorizing patients with CIC as having either FFR or SCT, allowing for different treatments. Radionuclear transit scintigraphy provides more detail and greater sensitivity than solid marker studies in diagnosing CIC. Radionuclear transit scintigraphy showed that half of our patients had SCT.

Section snippets

Patient characteristics

A retrospective review of 101 consecutive nuclear transit studies performed on children with severe constipation over a 2-year period was undertaken. All patients were seen by the senior author (JMH) or a gastroenterologist/pediatrician working in a continence clinic. All patients had symptoms of severe chronic constipation and/or encopresis that had not responded to at least 6 months of medical therapy with laxatives, dietary alterations, and behavior modification. Children with an obviously

Results

Between October 1997 and October 1999, 101 consecutive patients (62 boys and 39 girls) were retrospectively included in the study. The mean age at investigation was 7.3 ± 3.7 (mean ± SD) years.

Discussion

These results suggest that scintigraphy can be used in the investigation of chronic constipation in children and that the proposed advantages of scintigraphy over radio-opaque marker studies in the investigation of adults with chronic constipation also apply to children. Visual assessment of the images acquired at 6, 24, 30, and 48 hours allows patients to be categorized as having normal transit (n = 24), slow transit (n = 50), and FFR (n = 22). This categorization is clinically important

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      Citation Excerpt :

      One study observed a predominance of slow transit patients.17 Another demonstrated a higher percentage of children with DR.18 This variability may be related to differences in criteria to send patients for test (initial reports only sent patients without fecal retention)19; technique for the performance of NTS, involving preparation of the patient, and type and mode of meal ingestion; and finally, differences in phases of image acquisition. The current study prescribed a cleansing enema for fecal impaction before the NTS; this decision was based on the understanding that a hard fecal mass could interfere with gastrointestinal transit studies, since children with hard fecal mass usually avoid stool passage due to pain or discomfort.20,21

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    This study was supported in part by a Royal Children's Hospital (Melbourne, Australia) grant.

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