Introduction

The global prevalence of pediatric functional constipation (FC) varies from 1 to 30% due to the heterogeneity of the studies in terms of target population sampling, method of data acquisition, diagnostic criteria, among others. Studies conducted by Osatakul et al. and Piriyanon et al. in Thai young children, utilizing Rome III criteria, indicated prevalence rates of 1.6% and 25%, respectively. However, there is currently no study on the prevalence of FC in Thai young children using the Rome IV criteria, mainly because no standardized questionnaire exists for this age group.

Aims & Methods

The Thai version of the Rome-IV Diagnostic Questionnaire for Pediatric Functional Gastrointestinal Disorder (R4PDQ)-Toddler was developed then authorized by the Rome foundation. Guardians of children aged 6-48 months from six hospitals in five regions of Thailand from August 2023 to February 2024 were surveyed with the questionnaire composed of demographic data, the R4PDQ-Toddler for defecation, and the associated factors of FC.

Results

With a 98.1% response rate, a total of 1,874 guardians participated. The prevalence of FC was 16.1% (95% CI 14.5%-17.8%). Most presenting symptoms were painful or hard bowel movements (81.5%), large diameter stools (77.5%) and excessive stool retention (72.2%). Independent associated factors were age >1 year [aOR=3.36 (95%CI 2.29-4.94)], first-degree relative history of constipation [aOR=2.48 (95%CI 1.85-3.35, fiber supplementation [aOR=7.85 (95%CI 3.56-17.30)], and stressful life events in family [aOR=1.41 (95%CI 1.03-1.92)].

Conclusion

The prevalence of FC in Thai young children has been increased. Older age, family history of constipation, stressful life events in the family and supplementary fibers were associated factors of FC, warranting further evaluation.

References

1. Benninga MA, Nurko S, Faure C, Hyman PE, Roberts ISJ, Schechter NL. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology. 2016;150(6):1443-55. e2.
2. Koppen IJ, Vriesman MH, Saps M, Rajindrajith S, Shi X, van Etten-Jamaludin FS, et al. Prevalence of functional defecation disorders in children: a systematic review and meta-analysis. The Journal of pediatrics. 2018;198:121-30. e6.
3. Tran DL, Sintusek P. Functional constipation in children: What physicians should know. World Journal of Gastroenterology. 2023;29(8):1261.

Disclosure

All authors have COI.

Introduction

Constipation is a prevalent gastrointestinal disorder, commonly assessed using the Rome IV (R-IV) criteria for functional constipation. However, there is often a disconnect between a patient’s subjective perception of constipation and the clinical criteria used for diagnosis. Patients may either perceive constipation when they do not meet the diagnostic criteria or fail to recognize it despite fulfilling the criteria. This gap in understanding can lead to over- or under-diagnosis and inappropriate treatment.

Aims & Methods

This study aimed to investigate the association between patients' subjective perception of constipation and the fulfillment of Rome IV (R-IV) diagnostic criteria, addressing potential discrepancies that may impact clinical diagnosis and management. A cross-sectional study was conducted with 501 participants from the National Hospital Sri Lanka, who completed a self-reported questionnaire assessing bowel habits. Participants were categorized into four groups based on perceived constipation and R-IV fulfillment. Pearson’s chi-square test evaluated the association between these variables, while logistic regression analyzed predictors (gender, physical activity, water intake, stool consistency, and manual maneuvers) of constipation perception.

Results

Among the 501 participants (51.1% female), 36% reported perceiving constipation, whereas 25.5% met the R-IV criteria for functional constipation. A significant association was found between perceived constipation and R-IV criteria fulfillment (χ² = 12.77, p < 0.001). Notably, 23.6% of participants (Group 2) perceived constipation without fulfilling the criteria, while 13.0% (Group 3) met the criteria without perceiving constipation. Only 12.6% both perceived constipation (Group 1) and met the R-IV criteria, and 50.9% (Group 4) neither perceived constipation nor met the criteria. Manual defecation maneuvers were reported by 20.8% of participants, with digital evacuation (49%), bidet use (32.7%), and water enemas (31.7%) being the most common. The logistic regression model was statistically significant (χ²(5) = 60.222, p < 0.001), explaining 15.5% of the variance (Nagelkerke R²) and correctly classifying 70.7% of cases. Participants requiring manual maneuvers were 5.17 times more likely to report constipation (p < 0.001), while higher Bristol Stool Category scores were associated with a reduced likelihood of constipation perception (OR = 0.85, p = 0.009). Gender, physical activity, and water intake did not significantly influence the model.

Conclusion

This study highlights the significant association between perceived constipation and fulfillment of the Rome IV criteria. However, a substantial proportion of participants either perceive constipation without meeting the criteria or meet the criteria without recognizing the condition. These findings emphasize the limitations of relying solely on patient-reported symptoms, which may not always align with clinical diagnoses. A comprehensive approach that integrates objective diagnostic measures and patient perception could enhance diagnostic accuracy, reduce unnecessary interventions, and improve patient care in resource-limited settings like Sri Lanka.

References

Drossman, D. A., & Hasler, W. L. (2016). Rome IV—Functional GI Disorders: Disorders of Gut-Brain Interaction. Gastroenterology, 150(6), 1257–1261. https://doi.org/10.1053/j.gastro.2016.03.035

Introduction

Constipation is a common anorectal symptom that causes significant changes in the patients' quality of life. Anorectal manometry (ARM) and magnetic resonance (MR) defecography are important tools in diagnosing disorders associated with constipation, which are mainly structural and/or functional. Pelvic floor dyssynergia is diagnosed in the presence of alterations in 2 of the following: defecation kinetics in ARM, balloon expulsion test (BET) and/or MR defecography.

Aims & Methods

Compare the findings in ARM and MR defecography, in patients with constipation.
Retrospective cohort study including patients who fulfilled the Roma IV criteria for functional constipation, who were submitted to ARM and MR defecography. The London classification was used to describe the findings in ARM, establishing 3 groups of patients: Group 1 with those who had normal anorectal coordination and normal BET, Group 2 had altered anorectal coordination and altered BET, and Group 3 with those who had inconclusive findings: altered anorectal coordination and normal BET or normal anorectal coordination with abnormal BET. The structural alterations considered significant in MR defecography were those described as moderate to severe, which lead to defecation obstruction.

Results

A total of 51 patients were included, most were female (98.0%), with a mean age of 55 ± 12 years. Regarding the ARM findings, 16 patients were in Group 1 (31.4%), 11 in Group 2 (21.6%) and 24 in Group 3 (47.1%). Forty-three patients had alterations in MR defecography (84.3%), with 42 patients having at least one structural alteration and the most common being rectocele (72.5%) and descending perineum syndrome (66.7%). Pelvic floor dyssynergia was diagnosed by MR defecography in 9 patients (17.6%).
In the group of patients with normal anorectal coordination in ARM and normal BET (Group 1: n=16), 14 had significant structural alterations in MR defecography (87.5%) and 2 patients had no alterations (12.5%). In the group of patients with altered anorectal coordination in ARM and altered BET (Group 2: n=11), 8 also had structural alterations in MR defecography (72.7%). In the group of patients with inconclusive findings in ARM (Group 3: n= 24), 20 had structural alterations (83.3%) and 3 patients had pelvic floor dyssynergia diagnosed by MR defecography (12.5%), 2 of whom had both alterations (8.3%). In this group, 3 patients had no alterations in MR defecography (12.5%).
Patients with pelvic floor dyssynergia, with or without structural alterations, had a significantly lower rectoanal pressure differential than those with solely structural alterations (-25.0 ± 27.1 vs 5.7 ± 30.0 mmHg, p=0.004). There were no statistically significant differences in the values of anal pressure at rest and voluntary contraction pressure between patients with pelvic floor dyssynergia and those with solely structural alterations (p=0.350 and p=0.833), as well as in the values of residual anal pressure, intrarectal pressure and percentage of relaxation during defecation (p=0.267, p=0.257 and p=0.348).

Conclusion

Most patients had alterations in MR defecography, regardless of the ARM findings. Therefore, it is important to interpret the results of the ARM in conjunction with an imaging test capable of identifying structural alterations that may condition defecation in patients with functional constipation. In addition, those with pelvic floor dyssynergia, with or without associated structural alterations, had a lower rectoanal pressure differential than those with solely structural alterations.

Introduction

Functional diarrhea (FDr) is a disorder of gut-brain interaction (DGBI) characterized by chronic or recurrent diarrhea, not explained by structural or biochemical abnormalities. It is distinct from diarrhea predominant irritable bowel syndrome (IBS) with recurrent symptoms and notably the absence of pain. While functional conditions present with complex, likely heterogenous pathophysiology, we aimed to investigate if proxy measures of sociocultural risk factors have any association with the prevalence of FDr in populations across the world.

Aims & Methods

We performed an ecological study utilising peer-reviewed published datasets reporting country prevalence of FDr¹, Helicobacter pylori (H.p) prevalence² as proxy measures for orofecal infections, and the density of quick service restaurants (QSR) per population as proxy measure for processed food exposure. In addition, we used proxy measures of development including household size, median age, gross domestic product (GDP) per capita. The data were retrieved from publicly accessible datasets (United Nations, CIA, World Bank, commercial/financial reports of a global QSR chain). Spearman rank correlations were used to test univariate associations.

Results

The prevalence of FDr in 33 countries was negatively correlated with both the number of people per QSR (r= -0.44, p= 0.02), and household size (r= -0.69, p <0.0001), while positively correlated with median age (r= 0.58, p= 0.004) and GDP/capita (r= 0.56, p= 0.006). Assocaitions with H.Pylori infection did not reach significance (r= -0.27, p= 0.16).

Conclusion

Utilising publicly available data, the prevalence of FDr across diverse countries are linked to various markers of social development and a proxy marker of processed food consumption.

References

1. Sperber AD, Bangdiwala SI, Drossman DA, et al. Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study. Gastroenterology 2021;160:99-114 e3.
2. Hooi JKY, Lai WY, Ng WK, et al. Global Prevalence of Helicobacter pylori Infection: Systematic Review and Meta-Analysis. Gastroenterology 2017;153:420-429.

Disclosure

Nil

Introduction

Up to 30% of the under 18 years age group suffer from functional constipation with significant impact on health-related quality of life. In addition to lifestyle and dietary modifications, the currently available medication (e.g. polyethylene glycol, lactulose, stimulant laxatives) have low response rates, frequent side-effects, and non-sustained effects. Lubiprostone is an oral chloride channel-2 activator that stimulates gastrointestinal fluid secretion, softens stools, and facilitates bowel movements. It is approved in the United States for the treatment of chronic idiopathic constipation in adults. The evidence about the effectiveness and safety of lubiprostone in pediatric age group is still limited, representing a gap in clinical practice.

Aims & Methods

Aim: To evaluation of the effectiveness and safety of lubiprostone in children and adolescents with functional constipation.
Patients and Methods: In an open label, randomized, controlled trial, we included 277 patients in the age group 8-18 years diagnosed as functional constipation (FC). The diagnosis of FC was dependent on ROME IV criteria. After physical evaluation, patients were randomly (Simple randomization) assigned to one of 2 arms. First arm (n =137): patients received lubiprostone at doses of 24 mcg/day on divided doses or 24 mcg BID if weighing < 50 kg or ≥ 50 kg, respectively. Second arm (control, n = 140): patients received Bisacodyl, lactulose, or Sodium Picosulfate in appropriate doses. Treatment extended for 12 weeks followed by 4 weeks follow-up after treatment cessation (week 16). Evaluation during the study was done at baseline, weeks 2, 8, 12, and 16 of the study. The primary endpoint was spontaneous bowel movements (SBM) at week 12 and 16 compared to baseline. Improvement in the constipation was defined as increased SBM ≥ 1 SBM/week in frequency compared with baseline and maintaining ≥ 3 SBMs/week for at least 8 weeks (including the last 4 study weeks and the 4 weeks of follow-up). Safety assessment was done at clinic visits and by telephone as well as recording of patient-reported AEs.

Results

The two arms were matched as regards the mean ± SD of SBM at baseline (1.23 ± 0.37 motions/week for lubiprostone vs. 1.19 ± 0.28 motions/ week for control, P = 0.24). the primary endpoint was achieved in 128 (93.4%) patients of lubiprostone group, and in 48 (34.3%) patients of the control group (p < 0.001, ꭓ² = 105.42). In subgroup analysis, lubiprostone was superior to different laxatives in the control arm (p< 0.001, F = 95.6). At 12 weeks, the mean SMB in lubiprostone arm was (4.78 ± 0.99 motion/week) vs. (2.70 ± 1.04 /week) for control group (P <0.001). This difference was sustained for 4 weeks follow-up in lubiprostone group only. The overall side-effects occurred among 46% of lubiprostone group, and 48% in control group (p = 0.99). The most common adverse event in lubiprostone group were colicky abdominal pain (26%), and headache (14%), There was no life-threatening drug-related adverse events.

Conclusion

Lubiprostone is superior to conventional laxatives, and well tolerated treatment for functional constipation in pediatric and adolescent age groups.

References

van den Berg MM, Benninga MA, Di Lorenzo C. Epidemiology of childhood constipation: a systematic review. Am J Gastroentero 2006;101:2401–9.
Hyams, J. S., Di Lorenzo, C., Saps, M., Shulman, R. J., Staiano, A., & van Tilburg, M. Childhood Functional Gastrointestinal Disorders: Child/Adolescent. Gastroenterology 2016; 150(6), 1456–1468.e2.
Levy EI, Lemmens R, Vandenplas Y, Devreker T. Functional constipation in children: challenges and solutions. Pediatric Health Med Ther. 2017 Mar 9;8:19-27. doi: 10.2147/PHMT.S110940.
Benninga, M. A., Hussain, S. Z., Sood, M. R., Nurko, S., Hyman, P., Clifford, R. A., et al. Lubiprostone for Pediatric Functional Constipation: Randomized, Controlled, Double-Blind Study With Long-term Extension. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association, 2022; 20(3), 602–610.e5.

Disclosure

Nothing to declare