Use of hydrocolonic sonography to monitor the effects of an enema: Pediatric...

Hydrocolonic sonography is used to determine the amount of enema needed and to avoid radiography.

In fecal incontinence, hydrocolonic sonography can evaluate colonic motility and measure the volume of enema needed.

In constipation, hydrocolonic sonography can visualize fecal impaction and evaluate colonic motility.

The diagnostic process includes pediatric surgical evaluation with detailed clinical history, physical examination, exact classification of the malformation, evaluation for associated defects, and a two-week defecation protocol.

The two-week defecation protocol is used to distinguish pseudo-incontinence with overflow and intact continent organ from true fecal incontinence due to incontinence of the continent organ.

Treatment always starts with intestinal purgation using polyethylene glycol (macrogol or movicol) to achieve a clean colon for evaluation.

The bowel management program includes individually tailored enema, anal hygiene with showering after every enema, physiotherapy, defecation protocol monitoring, and in many cases psychiatric workup.

Two pump systems can be used for hydrocolonic sonography: an electric pump system originally used for stoma irrigation, and a hand pump made for people with spina bifida.

For older patients with a non-intact continent organ, a catheter with a very big balloon is helpful.

With the electric pump, a Foley catheter 24 French with a 30 mL balloon blockage is used, the same system as used in Cincinnati.

For successful sonography, there should be no air in the colon, as air makes it difficult to monitor the abdomen with ultrasound.

The catheter should be cleared of any air before filling the colon.

Explanation and cooperation of the children is very important for successful hydrocolonic sonography.

Hydrocolonic sonography is performed in a special room, usually in the presence of parents.

Children are told to watch the water progress on the ultrasound screen during the procedure.

With a successfully cleaned colon, ultrasound shows lovely movement and allows contact with every colonic cell.

The time between filling the colon and the first movement can be measured and is called the adaptation period.

White spots on ultrasound represent air bubbles and indicate the colon is not totally clean.

The goal is to monitor whether the enema reaches the cecum and measure the volume needed to reach that point.

If the enema volume reaches the cecum, it should be as effective at cleaning the whole colon as a Malone antegrade enema.

Hydrocolonic sonography can visualize fecal impaction, showing a big fecal stone in the rectum in children with severe constipation.

The perfect toilet for children after enema is one where the child sits low with feet firmly fixed on the ground.

In a series of 20 adult patients (age 14+ years) with fecal incontinence after anorectal malformation surgery, all had constant social problems and constant soiling before treatment.

After receiving tailored enemas based on hydrocolonic sonography, 18 of 20 patients achieved continence at 6 and 12 month follow-up.

The two patients who continued to have incontinence and soiling problems were those who did not follow the regime and decided not to do rectal irrigation.