The Colorectal Quiz Episode 8 - Motility Disorders Part 1

Failure of medical management is defined as: patient has appropriate treatment but no appropriate response, patient cannot take treatment (e.g., kids with autism or cognitive problems), patient has persistent symptoms or pain with treatment, or failure to grow.

If retrograde enemas for constipation management don't work, this is considered failure of medical management.

Reliance on rectal therapy or retrograde enemas with continued soiling causing significant effect on functioning as a young child is considered failure of medical management.

At the general pediatrician level, constipation medications typically include osmotic laxatives like MiraLax or lactulose and stimulant laxatives such as Senna or bisacodyl, but there are other medications pediatricians are probably not used to prescribing that GI doctors are.

Initial evaluation includes detailed history (triggers, stooling frequency, sensation of complete evacuation), physical exam (abdominal exam for palpable stool and distension), rectal exam, abdominal X-ray, and water-soluble contrast enemas.

In patients with long-standing constipation where appropriate treatments have been tried and failed, the first step in management is diagnostic studies, starting with contrast enema to assess degree of colonic dilation and/or redundancy and ensure the ratio is normal.

Motility utility of the colon is critical to patient management because in the past, colons or sigmoid colons were resected based on appearance, but patients had motility disorders and didn't need resection.

Many dilated colons will respond to treatment.

Water-soluble contrast (not barium) is used for contrast enemas because it helps empty the colon and acts as a cleanout for patients starting new medical therapy.

Anorectal manometry uses a catheter with sensors measuring pressure and a balloon; as the balloon inflates, pressures and responses are measured, particularly how the internal anal sphincter responds.

High pressures on anorectal manometry may suggest underlying issues with inability to relax, causing a functional obstruction.

Patients with Hirschsprung disease would have an absent rectoanal inhibitory reflex (RAIR) on anorectal manometry.

Anorectal manometry is vital for understanding the sphincter and its major role in patient management.