Bowel management

Fecal continence, or control of the bowels is an important achievement in a child's development. For children born with anomolies of the large bowel (anorectal anomalies and Hirschprung's disease) or anomalies of the innervation of the pelvic organs (such as spina bifida), the process of toilet training is challenging and often requires medical intervention.

The goal of the bowel management program is to teach patients and their parents or guardians how to administer a daily enema in order to clean and quiet the child's colon to prevent accidents. This is an important step in establishing independence and freedom. Achieving bowel control makes going to school and participating in activities outside the home possible for children with even the most severe physical anomalies.

For a patient with true fecal incontinence, bowel control is possible through the use of daily enemas tailored specifically for each patient. The program may include laxatives or other medications as well as the use of a controlled diet. The program lasts approximately one week. Each day the child is given an enema in a controlled environment. After passing stool, the child's abdomen is X-rayed in order to monitor the amount and location of any stool left in the colon.

Each afternoon, the clinical team meets to discuss and review the X-ray. through trial and error, the medical staff can determine the correct amount and type of enema suitable for each patient and determine whether dietary restrictions or medicatios are needed to help the child control his or her bowels.

History

The Colorectal Center for Children at Cincinnati Children's Hospital Medical Center was founded by Alberto Pena, MD, and Marc A. Levitt, MD. It is the first and only pediatric Colorectal Center in the world and thus provides care to children from all over the world with a unique, comprehensive and multidisciplinary approach.

Fecal incontinence

The medical definition of fecal incontinence is: The incapacity to voluntarily hold feces in the rectum. There are two subgroups to those with fecal incontinence: Real fecal incontinence and Pseudoincontinence

Real fecal incontinence

For a child with real fecal incontinence, the normal mechanism of bowel control is not working. An alteration of the muscles that surround the anorectal canal along with poor sphincters (those muscles which control the anus) are responsible for fecal incontinence in children operated on for anorectal malformations with a bad prognosis. Some patients operated on for Hirschsprung's disease have this anatomic problem as do those with spinal problems. The innervation (supply of nerve connections) of these muscles is important for their correct function. A deficit of the innervation occurs in anorectal anomalies as well as in other conditions. For example, in cases of Spina Bifida, or following spinal cord injury, the contraction and relaxation of the muscles, as well as sensastion, are both deficient. Thus, the presence and the passage of stool and the perception of the difference between solid and liquid stool and gas are limited.

Pseudoincontinence

In cases of pseudoincontinence, a child is believed to suffer from fecal incontinence. However, investigatino shows that he or she suffers from severe constipation and fecal impaction. When the impaction is treated and the patient recieves enough laxatives to pass stool, he or she becomes continent.

Candidates for Bowel Management

Children who suffer from fecal incontinence after the repair of an imperforate anus are usually those born with a bad prognosis type of defect and severe associated defects (defect of the sacrum, poor msucle complex). However, children who were born with a poor prognosis type of defect can still achieve a good quality of life when treated with the bowel management program. Children operated on for imperforate anus and who suffer from fecal incontinence can be divided into two groups that require individualized treatment plans:

Children with Constipation (Colonic Hypomotility) No special diet or medications are necessary for children with colonic hypomotility or constipation. Their tendency towards constipation helps them to remain clean between enemas. The real challenge is to find an enema capable of cleaning the colon completely. soiling episodes or "accidents" occur when there is an incomplete cleaning of the bowel.

Children with Loose Stools and Diarrhea (Colonic Hypermotility) This group fo children has an overactive colon. Rapid transit of stool resutls in frequent episodes of diarrhea. This means that even when an enema cleans the colon rather easily, stool keeps on passing fairly quickly from the cecum to the to the descending colon and the anus. To prevent this, a constipating diet and/or medications to slow down the colon are necessary. Eliminating foods that further loosen bowel movments will help the colon to slow down. Those who experience hypermotility may have to follow a constipating diet and avoid laxative foods. The diet is rigid and includes food such as banana, apple, baked bread, white pasta with no sauce, boiled meat, and others. While fried foods and dairy products are avoided.

Bowel Management Program

The bowel management program is tailored to individual patients and differs from child to child (Since anorectal malformations are a spectrum of severity). A routine is usually achieved within a week while the family , patient, physician and nurse undergo a process of trial and error designing the program to the specific patient. This requires a great deal of effort and dedication but the results are significant.

The bowel management program consists of teaching the patient or his/her parents how to clean the colon once daily so as to stay completely cleanin the underwear for 24 hours. We do this by keeping the colon quiet in between enemas. The program, although simplistic, is implemented by trial and error over a period of one week. the patient is seen each day and an x-ray folm of the abdomen is taken so that we may monitor, on a daily basis, the amount and location of any stool left in the colon as well as the presence of stool in the underwear. We then decide whether the type and/or quality of the treatment should be modified as well as diet and/or medication.

Overall, the bowel management program has a 95 percent success rate.

Type of Defect	Sex	Voluntary Bowel Movement	Soiling	Voluntary Bowel Movement Never Soiling	Constipation
Perineal Fistula	F/M	100%	0%	100%	26%
Anal Atresia or Stenosis	F/M	100%	16%	84%	80%
Vestibular Fistula	F	94%	38%	71%	64%
Bulbar Fistula	M	88%	65%	32%	59%
ARM without fistula	F/M	85%	41%	71%	47%
Cloaca Common Channel <3 cm.	F	83%	78%	27%	32%
Prostatic Fistula	M	76%	78%	28%	50%
Real Vaginal Fistula	F	75%	100%	0%	25%
Cloaca Common Channel >3cm.	F	59%	89%	22%	53%
Bladder-Neck Fistula	M	28%	100%	0%	29%

Frequently Asked Questions

At What Age Should My Child Begin Bowel Management? Children who suffer from fecal incontinence are basically oblivious to their condition when they are young and in diapers. Problems begin when their peers begin to wear underwear while they remain in diapers. This is the time when social discriminatoin may start. Toilet training for stool is a long-term goal for children with anorectal malformations, although it is not always possible. Parents of children born with a good prognosis type of defect should be encouraged to use the same strategies for toilet training as those followed by families with typical children.

What is the Best Time of Day to Administer an Enema? The timing of the enema plays a role in how efficiently it cleans the bowel. We recommend that you give an enema after th emain meal of the day to take advantage of the gastrocolic reflex (this motion of the colon happens after each meal). Most families give the enema in the evening when there is more time. Consider what time of the day will work best for your family. It is important to give the enema at the same time every day in order to create a routine. Keep in mind that if the enema is given every other day that the child should expel the amount of stool for two days. No more than 48 hours should elapse between enemas.

Why Not Use a Micro-Enema? Administration of a micro-enema to a child that is severely constipation only cleans the very last part of the rectum. This leaves the colon full of stool, now softened by the micro-enema, and the stool will leak more easily. If the goal of bowel control is reached and the child is clean, this regimen is acceptable.

Do Daily Enemas Interfere With Nutrition? It's common to worry that enemas affect the absorption of nutrients. It is very important for families to remember that when enemas are given, it is the colon that is being washed. Only stool, which is waste, is being removed. The main absorption of nutrients occurs in the small bowel, and enemas do not wash that part of the intestine.

The Future

Patients born with a poor prognosis type of defect will continue to need bowel management for life. However, some patients may gain some degree of bowel control. As time goes by children become more cooperative and more interested and concerned about their problem, thus making them more likely to achieve success with toilet training.

It is conceivable that later in life a child may stop using enemas and remain clean following a specific regimen of a disciplined diet with regular meals to provoke bowel movements at a predictable time.

Every summer, the children with some potential for bowel control can try, on an experimental basis, to find out how well they can control their bowel movements without the help of enemas. This is best done during summer vacation or a prolonged time at home to avoid accidents at school. This is called a laxative trial.

Many preschool and school-age children enjoy a good quality of life while undergoing the bowel management program. However, when they reach puberty, many express a high degree of dissatisfaction. They feel that thier parents are intruding on their privacy by giving them the enemas, and it is difficult for them to administer the enema themselves. For this group, an operatin called a continent appendicostomy or a Malone procedure has been designed. The Malone procedure allows the child to administer the enema by inserting a small catheter into the orifice at the belly button while sitting on the toilet. It is very easy and comfortable for any child to do.

</gallery>==External links==

• http://www.cincinnatichildrens.org/svc/alpha/c/colorectal/imperforate-anus/patients-families/bowel-manage/fecal-incontinence-types.htm
• http://www.cincinnatichildrens.org/svc/alpha/c/colorectal/default.htm?WT.mc_id=100200
• http://www.cincinnatichildrens.org/svc/alpha/c/colorectal/imperforate-anus/patients-families/bowel-manage/default.htm

References

Pena, A. The Bowel Management Program. Colorectal Center for Children. CCHMC. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

Marc Levitt. "Bowel Management". Cincinnati Children's Hospital Medical Center. {{cite journal}}: Check |authorlink= value (help); Cite journal requires |journal= (help); External link in |authorlink= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)