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 Proctology

Fissure-In-Ano, to Divide or Not to Divide ?

by T. Brugman, L. Bruyninx and N. J. Jacquet - 1/10/1999

Acta chir belg, 1999, 99, 215-220

Dept. of Surgery, University Hospital Sart-Tilman, Liège, Belgium.

Key words. Anal fissure , pathogenesis , symptoms , treatment , internal anal sphincter hypertonia , sphincterotomy , botulin toxin , glyceryl trinitrate , review.

Abstract. Anal fissure is one of the most common and painful proctological pathologies affecting mainly young individuals. The physiopathology in the development of a chronic anal fissure seems to be a combination of internal anal sphincter hypertonia and poor vascularization at the posterior midline. Treatment of acute fissures is conservative with supportive therapy, leading to healing in the majority of the patients. Open or closed lateral internal sphincterotomy is the treatment of choice for chronic anal fissures. In low pressure chronic fissures, sphincterotomy should be avoided and a V-Y island advancement flap may be an alternative procedure. Sphincterotomy can induce anal incontinence, a feared complication of this technique. Recent interest has developed in chemical sphincterotomy with local botulin toxin injections or glyceryl trinitrate application. Long-term follow-up is needed to evaluate these new therapeutic options.


1. Pediatric Anorectal Disorders.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24).
Language(s) (LG): English.
Year Published (YR): 2001.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): Di Lorenzo, C.
Source (SO): Gastroenterology Clinics of North America. 30(1): 269-287. March 2001.
Availability (AV): Available from W.B. Saunders Company. 6277 Sea Harbor Drive, Orlando, FL 32821-9816. (800) 654-2452.
Abstract (AB): Anorectal disorders are common in children; it is estimated that 10 percent of children are brought to medical attention because of a defecation disorder, and constipation is the chief complaint in 3 to 5 percent of all visits to pediatricians. This article explores pediatric anorectal disorders, emphasizing the differences between children and adults in terms of clinical presentations, pathophysiology, diagnosis, and treatment. Topics include constipation, functional nonretentive fecal soiling, Hirschsprung's disease, other colonic neuromuscular disorders, children with neurologic handicap (including cerebral palsy and spinal dysraphism), and imperforated anus. The author stresses that the child's developmental stage; the interaction between patient, family, and peers; and the presence of behavioral and psychological comorbidity need to be assessed carefully in any diagnosis of pediatric anorectal disorders. There are three periods when a child is particularly vulnerable to developing constipation: the introduction of cereals and solid food in the diet of an infant, toilet training, and the start of school. Childhood functional constipation is a clinical diagnosis that can be made in most cases on the basis of a typical history and an essentially normal physical examination. The most successful approach to a child with functional constipation includes a combination of parental education, behavioral modification, and medial intervention. 3 figures. 2 tables. 58 references.
Major Descriptors (MJ): Digestive System Diseases. Children. Constipation. Incidence. Etiology. Diagnosis. Therapy. Patient Care Management. Anorectal Disease. Functional Colonic Disorders.
Minor Descriptors (MN): Diagnostic Tests. Pathogenesis. Physiology. Symptoms. Drug Therapy. Patient Selection. Defecation. Fecal Incontinence. Diet Therapy. Behavior Modification. Rehabilitation. Patient Education. Parent Education. Neurological Disorders. Hirschsprung Disease.
Verification/Update Date (VE): 200107.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 08363.

2. Review of the Causes of Lower Gastrointestinal Tract Bleeding in Children.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24). REVIEW (46).
Language(s) (LG): English.
Year Published (YR): 2001.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): Rayhorn, N.; Thrall, C.; Silber, G.
Source (SO): Gastroenterology Nursing. 24(2): 77-83. March-April 2001.
Availability (AV): Available from Williams and Wilkins. 351 West Camden Street, Baltimore, MD 21201-2436. (410) 528-8555.
Abstract (AB): Bleeding may occur anywhere along the gastrointestinal (GI) tract, which covers a large surface area and is highly vascularized. Pediatric patients who present with blood in their stools (bowel movements) are a special challenge for the health care team. Seeing blood in the child's stools, the caregiver and child may become extremely anxious, fearing a devastating diagnosis. This article reviews the causes of lower GI tract bleeding in children. The differential diagnosis of this symptoms in infants and children includes numerous possibilities ranging from benign disorders, which require little or no treatment at all, to serious diseases that require immediate intervention. A complete history, including progression, duration, frequency, and severity of symptoms, is essential in assessing GI bleeding. Associated symptoms that help define the diagnosis include vomiting, diarrhea, constipation, abdominal pain, anorexia (lack of appetite), rash, joint pain or swelling, weight loss, fever, irritability, history of GI bleeding, or history of hematological or immunological disorders. Constipation with fissure (a tear in the anus) formation is the most common cause for rectal bleeding in toddlers and school age children. Infection is one of the more common causes of bleeding from the lower GI tract; infections can be due to Salmonella, Shigella, Campylobacter jejuni; Yersinia enterocolitica, Escherichia coli, Clostridium difficile, or Entamoeba histolytica. Other causes include swallowed blood, hemorrhoids, inflammatory bowel disease (IBD), intussusception (a portion of the bowel turns in on itself, creating an obstruction), polyps, lymphonodular hyperplasia, Meckel's diverticulum, allergic colitis, Henoch Schonlein purpura, hemolytic uremic syndrome (HUS), enterocolitis, child sexual abuse, and Munchausen syndrome by proxy.
Major Descriptors (MJ): Digestive System Diseases. Gastrointestinal Bleeding. Hemorrhage. Children. Etiology. Symptoms. Diagnosis.
Minor Descriptors (MN): Infants. Diagnostic Tests. Risk Factors. Constipation. Abdominal Pain. Diarrhea. Bacterial Infections. Patient Care Management. Nursing Care. Fissure. Hemorrhoids. Inflammatory Bowel Disease.
Verification/Update Date (VE): 200107.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 08368.

3. Childhood Constipation: Finally Some Hard Data About Hard Stools! (editorial).

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24).
Language(s) (LG): English.
Year Published (YR): 2000.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): DiLorenzo, C.
Source (SO): Journal of Pediatrics. 136(1): 4-7. January 2000.
Availability (AV): Available from Mosby, Inc. 11830 Westline Industrial Drive, St. Louis, MO 63146-3318. (800) 453-4351 or (314) 453-4351. Fax (314) 432-1158. Website: www.mosby.com.
Abstract (AB): It is estimated that 55 million adults in the United States (approximately 28 percent of the population) are constipated. Similar data are not available on the prevalence in children, although it has been reported that 34 percent of toddlers in the United Kingdom and 37 percent of Brazilian children younger than 12 were considered by their parents to be constipated. This editorial offers a review of the literature on childhood constipation, focusing on research studies that quantified the prevalence of the problem. The editorial also serves as an introduction to two related articles in the same issue of Journal of Pediatrics. The author notes that the most common cause of constipation in pediatrics is a decision made by the child to delay defecation after experiencing a painful or frightening evacuation. Treatment is based on addressing all the factors that have contributed to its development. The evacuations are made more pleasant by stool softeners. The fear of defecation is overcome by avoiding anally invasive procedures (such as enemas) and by using positive reinforcement to make the process less intimidating. Key to successful treatment is a thorough understanding by the family of the pathophysiology of childhood constipation. The author applauds the authors of the other articles for addressing this poorly studied subject. Progress in the understanding of colonic motility disorders and the pathophysiologic mechanisms responsible for treatment failures will help in the selection of patients who may benefit from the use of cisapride and dietary changes. Development of safe prokinetics with a more selective action on colonic motility will undoubtedly facilitate their use in the treatment of childhood constipation. 12 references.
Major Descriptors (MJ): Digestive System Diseases. Constipation. Children. Epidemiology. Etiology. Therapy.
Minor Descriptors (MN): Patient Care Management. Psychological Factors. Gastrointestinal Motility. Drug Therapy. Diet Therapy. Pathophysiology. Prevalence. Behavior Modification.
Verification/Update Date (VE): 200004.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 07575.

4. Cisapride for the Treatment of Constipation in Children: A Double-Blind Study.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24).
Language(s) (LG): English.
Year Published (YR): 2000.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): Nurko, S., et al.
Source (SO): Journal of Pediatrics. 136(1): 35-40. January 2000.
Availability (AV): Available from Mosby, Inc. 11830 Westline Industrial Drive, St. Louis, MO 63146-3318. (800) 453-4351 or (314) 453-4351. Fax (314) 432-1158. Website: www.mosby.com.
Abstract (AB): This article reports on a study undertaken to determine whether cisapride is effective in treating children with constipation. The double blind, placebo controlled study included children with chronic constipation who were randomly assigned to treatment with cisapride or placebo for 12 weeks. Forty children were enrolled, and 36 completed the therapy. Treatment successes occurred in 13 of 17 subjects in the cisapride group (76 percent) and 8 of 19 subjects in the placebo group (37 percent). The odds ratio for response after cisapride administration was 8.2 times higher. During cisapride therapy, there was a significant improvement in the number of spontaneous bowel movements per week and a significant decrease in the number of fecal soiling episodes per day, percentage with encopresis, number of laxative doses per week, percentage using laxatives, and total gastrointestinal transit time. With placebo, there were no significant changes in the number of spontaneous bowel movements, percentage with encopresis, or total gastrointestinal time; but there was a significant decrease in the number of fecal soiling episodes per day and the number of laxative doses per week. The authors conclude that cisapride was effective in treating children with constipation. The authors note, however, that cisapride is not recommended as the first line drug for children with constipation. Dietary fiber and other behavior changes are recommended first. 1 figure. 2 tables. 27 references.
Major Descriptors (MJ): Digestive System Diseases. Constipation. Children. Drug Therapy. Cisapride.
Minor Descriptors (MN): Gastrointestinal Motility. Motility Disorders. Laxatives. Fecal Incontinence. Drug Effects.
Verification/Update Date (VE): 200004.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 07576.

5. Appendicitis in Children: New Insights Into an Old Problem.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24).
Language(s) (LG): English.
Year Published (YR): 2000.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): Gregory, T., ed.
Source (SO): Patient Care. 34(5): 183-188, 191-195. March 15, 2000.
Availability (AV): Available from Medical Economics. 5 Paragon Drive, Montvale, NJ 07645. (800) 432-4570. Fax (201) 573-4956.
Abstract (AB): Acute appendicitis is the most common reason for emergency abdominal surgery in childhood. Despite strong emphasis on early surgical intervention, the morbidity and mortality of acute appendicitis in children remain high. This review article clarifies the symptoms to look for in the patient's history, the signs to assess during the physical examination, and the degree of confidence to place in various laboratory tests and radiologic studies. The authors reiterate that a thorough but speedy evaluation is essential when examining a child with possible appendicitis. Recent studies show that in ambiguous cases, computed tomography (CT scan), especially when performed with rectal contrast, is an excellent adjudicator. The authors review the anatomy and physiology of the appendix, then detail each step of the physical examination. After a discussion of the appropriate laboratory tests, the authors remind readers of the more common pediatric illnesses that mimic appendicitis, including gastroenteritis, constipation, mesenteric adenitis, urinary tract infection (UTI), inflammatory bowel disease (IBD), pelvic inflammatory disease (PID), ovarian cyst, and pneumonia. 8 figures. 2 tables. 22 references.
Major Descriptors (MJ): Digestive System Diseases. Children. Appendicitis. Diagnosis. Diagnostic Tests.
Minor Descriptors (MN): Morbidity. Gastrointestinal Diseases. Anatomy. Physiology. Appendix. Abdominal Pain. Symptoms. Epidemiology. Patient Care Management. Physical Examination.
Verification/Update Date (VE): 200007.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 07704.

6. Childhood Defecation Disorders: Constipation and Soiling.

Subfile: Digestive Diseases
Format (FM): NEWSLETTER ARTICLE (35).
Language(s) (LG): English.
Year Published (YR): 2000.
Audience code (AC): PATIENT (400).
Author (AU): Hyman, P.
Source (SO): Participate. 9(3): 4-6. Fall 2000.
Availability (AV): Available from International Foundation for Functional Gastrointestinal Disorders (IFFGD). P.O. Box 170864, Milwaukee, WI 53217. (888) 964-2001 or (414) 964-1799. Fax (414) 964-7176. E-mail: iffgd@iffgd.org. Website: www.iffgd.org.
Abstract (AB): This article is the second in a two part series on pediatric functional gastrointestinal (GI) disorders that may prompt parents to bring their child to the doctor for constipation or fecal soiling. In this article, the author focuses on non retentive fecal soiling and functional fecal retention. Functional refers to a disorder where the primary problem is not due to disease or visible tissue damage or inflammation; in this article, the author uses functional to refer to symptoms that occur within the expected range of the body's behavior. Functional fecal retention is defined in children by the passage of large or enormous bowel movements at intervals less than twice per week, and the attempt to avoid having bowel movements on purpose. Accompanying symptoms include soiling of the underclothes, irritability, abdominal cramps, and decreased appetite. Functional fecal retention begins when there is a painful bowel movement and the child learns to fear the urge to have a bowel movement. After diagnosis, treatment goals include family and patient education, medication as necessary to assure painless defecation, and the provision of continued availability and interest in the child's problem. Fecal soiling refers to passage of bowel movements into the underclothing, or other inappropriate places. Fecal soiling commonly accompanies functional fecal retention, or after a chronic problem with diarrhea. Functional non retentive (not associated with fecal retention) fecal soiling is diagnosed in children older than 4, who have bowel movements in places and at times that are inappropriate, at least once a week for 3 months, in the absence of a disease to explain it. Treatment goals are to help the parent to understand that there is no medical disease, and to accept a referral to a mental health professional. Parents need guidance to understand that soiling is a symptom of emotional upset, not simply bad behavior. 1 table.
Major Descriptors (MJ): Digestive System Diseases. Constipation. Defecation. Psychological Factors. Functional Colonic Disorders. Children. Fecal Incontinence. Impacted Feces.
Minor Descriptors (MN): Rectum. Parent Education. Patient Education. Behavior Modification. Prevention. Drug Therapy. Abdominal Pain. Diarrhea. Symptoms. Risk Factors.
Verification/Update Date (VE): 200104.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 08087.

7. Chronic Abdominal Pain in Childhood: Diagnosis and Management.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24). REVIEW (46).
Language(s) (LG): English.
Year Published (YR): 1999.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): Lake, A.M.
Source (SO): American Family Physician. 59(7): 1823-1830. April 1, 1999.
Availability (AV): Available from American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. (800) 274-2237. Website: www.aafp.org.
Abstract (AB): More than one third of children complain of abdominal pain lasting 2 weeks or longer. This article discusses the diagnosis and management of chronic abdominal pain in childhood. The diagnostic approach relies heavily on the history provided by the parent and child to direct a step wise approach to investigation. If the history and physical examination suggest functional abdominal pain, constipation, or peptic disease, the response to an empiric course of medical management is of greater value than multiple exclusionary investigations. A symptom diary allows the child to play an active role in the diagnostic process. The medical management of constipation, peptic disease, and inflammatory bowel disease involves nutritional strategies, pharmacologic intervention, and psychological support. The authors recommend careful followup to monitor compliance with treatment, restoration of normal activities, and appropriate family interventions. Support groups for the family and the child can be invaluable. Most important, the child must feel that the family physician understands that the pain is real, that the child's input is as valuable as the parents', and that information shared in confidence will be kept confidential if at all possible. One figure summarizes the algorithmic approach to the child with probable peptic disease. 1 figure. 3 tables. 19 references.
Major Descriptors (MJ): Digestive System Diseases. Abdominal Pain. Children. Chronic Disease. Diagnosis. Patient Care Management.
Minor Descriptors (MN): Symptoms. Diagnostic Tests. Patient History. Constipation. Vomiting. Peptic Ulcer. Nausea. Gastroesophageal Reflux Disease. Inflammatory Bowel Disease. Drug Therapy. Diet Therapy.
Verification/Update Date (VE): 200108.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 07201.

8. How to Resolve Stool Retention in a Child: Underwear Soiling is Not a Behavior Problem.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24).
Language(s) (LG): English.
Year Published (YR): 1999.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): Griffin, G.C.; Roberts, S.D.; Graham, G.
Series (SE): (Pediatrics Series).
Source (SO): Postgraduate Medicine. 105(1): 159-161, 165-166, 172-173. January 1999.
Abstract (AB): Many parents do not realize that their child has stool retention when they bring him or her for an office visit. This article guides primary care providers in the diagnosis and patient management of these children and their parents. The authors discuss how and why stool retention gets started, and they summarize the complaints parents often have when they bring in their child. A complete treatment regimen is described and compiled in a form that can be sent home with parents (a chart of strategies for parents to use immediately and on an ongoing basis). The authors note that stool retention is the most common cause of underwear soiling in children who have been toilet trained. Management begins with educating parents that leaking of liquid stool around impaction and onto underwear is completely involuntary, so the child should never be scolded or embarrassed. Stool retention may begin because of unpleasant or unavailable toilet facilities, constipation, or painful elimination and often becomes self perpetuating. The impaction must be removed immediately; magnesium citrate solution is usually effective. To allow the rectum to return to its normal size, which can take a long time, stool must be kept soft and movable with administration of mineral oil and appropriate dietary choices (e.g., fruit, juice, fiber). Recurrence is common, so ongoing measures and followup are important. 1 figure. 1 table. 16 references. (AA-M).
Major Descriptors (MJ): Digestive System Diseases. Constipation. Children. Obstruction. Impacted Feces. Patient Care Management.
Minor Descriptors (MN): Fecal Incontinence. Symptoms. Risk Factors. Etiology. Parent Education. Drug Therapy. Prevention. Dietary Fiber.
Verification/Update Date (VE): 200001.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 07080.

9. When 'Little Accidents' Turn Serious: Understanding Fecal Incontinence.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24).
Language(s) (LG): English.
Year Published (YR): 1999.
Audience code (AC): PATIENT (400).
Author (AU): Dorsky, R.; Dorsky, L.T.
Source (SO): Digestive Health and Nutrition. p. 22-25. November-December 1999.
Availability (AV): Available from American Gastroenterological Association. 7910 Woodmont Avenue, 7th Floor, Bethesda, MD 20814. (877) DHN-4YOU or (301) 654-2055, ext. 650. E-mail: DHN@gastro.org.
Abstract (AB): This article discusses fecal incontinence (encopresis) in children, delineating when this behavior becomes a serious problem and what actions to take to correct it. Fecal incontinence is defined as soiling of a child's underpants (or leaking of stool) at a time when the child should be toilet trained (after ages 2 to 3 for girls; 2 to 4 for boys). It occurs in conjunction with chronic constipation, which results when a child does not completely empty his or her bowel when sitting on the toilet, or refuses to use the toilet altogether. By becoming alert to the warning signs of encopresis, parents can often prevent the problem from worsening. The author reviews the common schedule a child will follow for defecation; the variety of factors that can contribute to the development of constipation, including toilet training forced at too young an age; not drinking enough fluids; holding back because of a particularly painful bowel movement in the past; stress in the family such as a birth, death, divorce, or unfamiliar surroundings; the child's typical behavior after soiling, notably denial; and strategies for addressing the problem of encopresis. One sidebar offers tips on toilet training.
Major Descriptors (MJ): Digestive System Diseases. Fecal Incontinence. Children. Constipation. Patient Care Management. Defecation.
Minor Descriptors (MN): Parent Education. Toilet Training. Psychosocial Factors. Fluids. Stress. Parent-Child Relations. Behavior Modification.
Verification/Update Date (VE): 200001.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 07337.

10. Pediatric Gastrointestinal Disease. 2nd ed.

Subfile: Digestive Diseases
Format (FM): MONOGRAPH/BOOK (32).
Language(s) (LG): English.
Year Published (YR): 1999.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): Wyllie, R.; Hyams, J.S., eds.
Source (SO): Philadelphia, PA: W.B. Saunders Company. 1999. 823 p.
Availability (AV): Available from W.B. Saunders Company. Book Order Fulfillment Department, 11830 Westline Industrial Drive, Saint Louis, MO 63146-9988. (800) 545-2522 or (314) 453-7010. Fax (800) 568-5136 or (314) 453-7095. E-mail: wbsbcs@harcourt.com. Website: customerservice.wbsaunders.com. PRICE: $155.00 plus shipping and handling. ISBN: 0721674615.
Abstract (AB): This medical textbook covers all facets of clinical pediatric gastrointestinal disease. The text emphasizes a clinical focus and incorporates anatomy and physiology considerations into each chapter rather than a separate section. The book is organized into distinct sections, starting with the common clinical problems and followed by organ specific diseases. General chapters on clinical problems cover chronic abdominal pain of childhood and adolescence, vomiting, diarrhea, constipation and encopresis (fecal soiling), failure to thrive, gastrointestinal hemorrhage, eating disorders and obesity, jaundice, ascites, caustic ingestion and foreign bodies, abdominal masses in pediatric patients, and abdominal surgical emergencies. Sections on diseases of the esophagus, stomach, and the small and large bowel (intestine) are followed by chapters reviewing the clinical facets of pediatric liver disease. Specific chapters include gastrointestinal reflux, achalasia and other motor disorders, congenital anomalies, gastric motility disorders, bezoars (a mass of food, hair or other components found in the stomach or intestine), maldigestion and malabsorption, celiac disease, short bowel syndrome, enteric parasites, Crohn's disease, ulcerative colitis, polyps, appendicitis, hernia, Hirschsprung's disease, neoplasms (cancerous and noncancerous), hepatitis, gallbladder diseases, and liver transplantation. The last two sections review diseases of the pancreas and basic nutrition in children, including pancreatitis, cystic fibrosis, nutritional assessment, parenteral (outside the digestive system, for example, intravenous nutrition) and enteral nutrition, and the management of diarrhea. Each chapter offers black and white photographs and figures and concludes with extensive references. A detailed subject index concludes the text.
Major Descriptors (MJ): Digestive System Diseases. Gastrointestinal System. Children. Adolescents. Diagnosis. Therapy. Symptoms. Patient Care Management. Pathophysiology.
Minor Descriptors (MN): Abdominal Pain. Vomiting. Diarrhea. Constipation. Hemorrhage. Eating Disorders. Liver Diseases. Ascites. Surgery. Drug Therapy. Congenital Anomalies. Stomach. Esophagus. Motility Disorders. Celiac Disease. Inflammatory Bowel Disease. Pancreas. Nutrition. Diagnostic Tests. Professional Education.
Verification/Update Date (VE): 200004.
Notes (NT): CP: Yes.
Accession Number (AN): DD BK 07495.

11. Nutritional Considerations Following Total Colectomy for Motility Disorders.

Subfile: Digestive Diseases
Format (FM): NEWSLETTER ARTICLE (35).
Language(s) (LG): English.
Year Published (YR): 1999.
Audience code (AC): PATIENT (400).
Author (AU): Vanderhoof, J.A.
Source (SO): Messenger. 9(3): 4-7. 1999.
Availability (AV): Available from American Pseudo-obstruction and Hirschsprung's Disease Society, Inc. 158 Pleasant Street, North Andover, MA 01845. (978) 685-4477. Fax (978) 685-4488.
Abstract (AB): This article reviews the nutritional considerations for patients following total colectomy (removal of the colon) for motility disorders. The article is from a newsletter for people with Hirschsprung's disease (HD), a motility disorder of the large bowel caused by absence of parasympathetic ganglion (nerve) cells. The most common symptom of HD is constipation; associated symptoms include abdominal pain and distention, bilious vomiting, anorexia, and failure to thrive. Once the diagnosis has been confirmed, the only definitive treatment of children with HD is operative relief of the functional obstruction. The author reviews colon anatomy and physiology, the consequences of resection, the use of parenteral nutrition (supplemental feeding that bypasses the gastrointestinal tract), and the use of enteral feeding (tube feeding). The author notes that the amount of bowel resected in HD is variable. Parenteral nutrition is useful in Hirschsprung's disease, particularly total colon Hirschsprung's disease, especially as necessary to maintain fluid and electrolyte balance. Enteral nutrition is often initially accomplished with tube feeding and ultimately, a modified oral nutrition program becomes the mainstay of nutrition. Of prime importance is a balanced nutritional program. Absolute restriction of any particular food group should be avoided unless a direct negative correlation with stool output is identified. 2 figures. 1 table.
Major Descriptors (MJ): Digestive System Diseases. Hirschsprung Disease. Children. Infants. Nutrition. Postoperative Care.
Minor Descriptors (MN): Colectomy. Postoperative Complications. Malnutrition. Enteral Nutrition. Parenteral Nutrition.
Verification/Update Date (VE): 200004.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 07364.

12. Functional Childhood Constipation: A Practical Approach.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24). REVIEW (46).
Language(s) (LG): English.
Year Published (YR): 1999.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): Khan, S.; Di Lorenzo, C.
Series (SE): (Pediatric Functional Bowel Disorders, Series Number 5).
Source (SO): Practical Gastroenterology. 23(12): 16, 20-22, 24-26, 33-34. December 1999.
Availability (AV): Available from Shugar Publishing, Inc. 99B Main Street, Westhampton Beach, NY 11978. (631) 288-4404. Fax (631) 288-4435. E-Mail: info@practicalgastro.com.
Abstract (AB): Constipation is a common childhood problem and is frequently encountered by the primary care physician and the pediatric gastroenterologist alike. Although the presentation of constipation in infancy raises concerns about organic etiologies, the large majority of infantile and childhood presentations of constipation have a functional basis. This review article emphasizes the concepts basic to the recognition and management of functional childhood constipation from the perspective of a primary care physician. Data obtained through a careful history and physical examination should enable the physician in most cases to confidently establish the diagnosis of functional constipation and exclude less common organic disorders. Infants and older children with atypical features or intractable constipation may require diagnostic investigations. Most children recover satisfactorily after being managed with a combination of incentive based behavior modification and stool softeners. The authors note that early recognition and initiation of behavior modification and pharmacotherapy in children favorably influences prognosis. Children with intractable constipation and those suspected of having underlying organic etiologies can therefore be identified by the primary care physician and referred to a subspecialist for further evaluation. 1 figure. 3 tables. 15 references.
Major Descriptors (MJ): Digestive System Diseases. Constipation. Children. Patient Care Management. Diagnosis. Therapy.
Minor Descriptors (MN): Infants. Diagnostic Tests. Etiology. Risk Factors. Behavior Modification. Drug Therapy. Dietary Fiber. Psychological Factors.
Verification/Update Date (VE): 200008.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 07571.

13. What to Do When Your Child Gets Sick.

Subfile: Digestive Diseases
Format (FM): MONOGRAPH/BOOK (32).
Language(s) (LG): English. Spanish.
Year Published (YR): 1999.
Audience code (AC): PATIENT (400).
Author (AU): Mayer, G.; Kuklierus, A.
Source (SO): Whittier, CA: Institute for Healthcare Advancement. 1999. 181 p.
Availability (AV): Available from Institute for Healthcare Advancement. 15111 East Whittier Blvd., Suite 460, Whittier, CA 90603. (800) 434-4633. Fax (562) 907-1963. Website: www.iha4health.org. PRICE: $14.95 plus shipping and handling; bulk copies available. ISBN: 0828114404.
Abstract (AB): This reference book uses simple everyday language and illustrations to provide information on common childhood illnesses and health problems. Written in nontechnical language designed to be accessible to adults at any reading level, the book features 11 topical chapters: safety tips, caring for the sick child, the newborn baby, the child's eyes, the child's ears and nose, the child's mouth and throat, the child's breathing, the child's stomach, bed wetting, the child's skin, and what to do when the child gets hurt. Topics related to digestive diseases include infection, jaundice, swallowing foreign objects, blood in the bowel movements, colic, constipation, diarrhea, food allergies, hernia, spitting up, stomach pain, vomiting, and poisoning. The book features extensive illustrations, with topics simplified to key points on each page. The book's content is simplified through the use of short, active sentences and single syllable words where appropriate. For most of the topics, the book follows a similar style covering a definition (what is it?), symptoms (what do I see?), how to care for the child (what can I do at home?), how to know when to call the doctor or nurse, and further information (what else should I know about this condition?). The book concludes with a word list (a glossary of terms), a subject index, and a list of acknowledgments. The book is available in either Spanish or English.
Major Descriptors (MJ): Digestive System Diseases. Children. Parent Education. Patient Care Management. Home Care. Symptoms. Diagnosis.
Minor Descriptors (MN): Limited Reading Skills. Patient Education. Delivery of Health Care. Risk Factors. Complications. Jaundice. Constipation. Diarrhea. Vomiting. Food Allergies. Abdominal Pain. Stomach.
Verification/Update Date (VE): 200007.
Notes (NT): CP: Yes.
Accession Number (AN): DD BK 07689.

14. Increasing Oral Fluids in Chronic Constipation in Children.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24).
Language(s) (LG): English.
Year Published (YR): 1998.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): Young, R.J.; Beerman, L.E.; Vanderhoof, J.A.
Source (SO): Gastroenterology Nursing. 21(4): 156-161. July-August 1998.
Availability (AV): Available from Williams and Wilkins. 351 West Camden Street, Baltimore, MD 21201-2436. (410) 528-8555.
Abstract (AB): Increasing the amount and type of fluid intake in children with simple constipation remains a common intervention recommended by both the medical profession and lay consumers. However, there is no research or physiologic basis for increasing overall water intake and or high osmolarity liquid intake in order to produce softer or more frequent stools. This article reports on a project undertaken to identify whether a concerted effort to increase liquid intake would lead to an effect on stooling characteristics. Ninety children completed the entire study as assigned (59 girls, 31 boys). Neither increasing water intake nor increasing hyperosmolar liquid intake significantly increased stool frequency or decreased consistency or difficulty with passage. The authors conclude that nurses need to be proactive in changing commonly held thoughts regarding the treatment of pediatric constipation. Advising new parents of what is acceptable in stooling patterns is important. Encouraging a high insoluble fiber intake is more beneficial in promoting healthy stool patterns than any amount of increased liquid intake. Advising parents of constipated children to increase liquid intake is not helpful and should not be recommended unless history suggests that the child's liquid intake is inadequate for a normal child of that age and activity level. 3 figures. 4 tables. 19 references. (AA-M).
Major Descriptors (MJ): Digestive System Diseases. Constipation. Children. Fluids. Fluid Therapy.
Minor Descriptors (MN): Dehydration. Defecation. Dietary Fiber. Colon. Physiology.
Verification/Update Date (VE): 199907.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 07023.

15. Bowel and Bladder Management.

Subfile: Digestive Diseases
Format (FM): BOOK CHAPTER (09).
Language(s) (LG): English.
Year Published (YR): 1997.
Audience code (AC): HEALTH PROFESSIONALS (100). COMMUNITY SERVICE PROFESSIONALS (200).
Author (AU): Blackman, J.A.
Source (SO): In: Blackman, J.A. Medical Aspects of Developmental Disabilities in Children Birth to Three. 3rd ed. Gaithersburg, MD: Aspen Publishers, Inc. 1997. p. 11-23.
Availability (AV): Available from Aspen Publishers, Inc. 7201 McKinney Circle, Frederick, MD 21704. (800) 234-1660 or (800) 638-8437. PRICE: $40.00. ISBN: 0834207591.
Abstract (AB): Many infants and young children with developmental disabilities have complex needs related to their bowel and bladder functions. This chapter is part of a book designed to educate health and social service professionals about the medical challenges presented by children (ages 1 to 3) with developmental disabilities. The chapter discusses the management of constipation, intestinal ostomies, and clean intermittent catheterization. For each topic, the author provides information about cause, incidence, medical management, course, accompanying health problems, and possible alternative treatments or problems. The author points out that bowel and bladder problems can interfere with education or therapy services. Black and white photographs and line drawings illustrate some of the concepts presented. 5 figures. 2 references. (AA-M).
Major Descriptors (MJ): Digestive System Diseases. Constipation. Congenital Disorders. Colostomy. Ileostomy. Children. Infants. Urination. Anus. Therapy. Equipment and Supplies. Gastrointestinal Diseases. Colon. Catheters.
Minor Descriptors (MN): Cathartics. Hirschsprung Disease. Diet. Enterocolitis, Pseudomembranous.
Verification/Update Date (VE): 199805.
Notes (NT): CP: Yes.
Accession Number (AN): DD BK 01863.

16. Hirschsprung's Disease.

Subfile: Digestive Diseases
Format (FM): FACT SHEET (22).
Language(s) (LG): English.
Year Published (YR): 1997.
Audience code (AC): PATIENT (400).
Corporate Author (CN): American Pseudo-obstruction and Hirschsprung's Disease Society, Inc. (APHS).
Source (SO): North Andover, MA: American Pseudo-obstruction and Hirschsprung's Disease Society, Inc. 1997. 2 p.
Availability (AV): Available from APHS. 158 Pleasant Street, North Andover, MA 01845-2797. (508) 685-4477. Fax (508) 685-4488. E-mail: aphs@mail.tiac.net. PRICE: Single copy free.
Abstract (AB): This fact sheet provides basic information about Hirschsprung's disease, its diagnosis, and treatment. Hirschsprung's disease is a serious childhood condition caused by the absence of nerve cells in the wall of the bowel. The portion of bowel without these nerve cells (ganglia) does not relax and remains collapsed. Bowel contents build up behind the obstruction. The most life-threatening emergency in Hirschsprung's disease is enterocolitis, a severe inflammatory condition of the bowel wall. To diagnose Hirschsprung's disease, a barium enema xray test is used to identify the narrow collapsed segment of bowel as well as the dilated bowel in front of the affected regions. A biopsy is then necessary to confirm the absence of ganglia. Treating Hirschsprung's disease requires surgery to remove the affected bowel and then join the healthy bowel segments. The fact sheet briefly reviews the three surgical techniques that are used to treat Hirschsprung's disease. The fact sheet concludes that, for most children with Hirschsprung's disease, there are no longterm complications after successful surgery. However, a significant minority of children are troubled with persistent constipation, encopresis (stool incontinence), or persistent enterocolitis. (AA-M).
Major Descriptors (MJ): Digestive System Diseases. Hirschsprung Disease. Health Education. Patient Education. Diagnosis. Surgery. Children.
Minor Descriptors (MN): Diagnostic Tests. Symptoms. Gastrointestinal Motility. Postoperative Complications. Physiology.
Verification/Update Date (VE): 199710.
Notes (NT): CP: Yes.
Accession Number (AN): DD DC 06046.

17. Chronic Intestinal Pseudo-Obstruction.

Subfile: Digestive Diseases
Format (FM): FACT SHEET (22).
Language(s) (LG): English.
Year Published (YR): 1997.
Audience code (AC): PATIENT (400).
Corporate Author (CN): American Pseudo-obstruction and Hirschsprung's Disease Society, Inc. (APHS).
Source (SO): North Andover, MA: American Pseudo-obstruction and Hirschsprung's Disease Society, Inc. 1997. 2 p.
Availability (AV): Available from APHS. 158 Pleasant Street, North Andover, MA 01845-2797. (508) 685-4477. Fax (508) 685-4488. E-mail: aphs@mail.tiac.net. PRICE: Single copy free.
Abstract (AB): This fact sheet provides basic information about the diagnosis and treatment of chronic intestinal pseudo-obstruction (CIP), the name given to a number of rare disorders that cause impaired gastrointestinal (GI) motility (movement in the digestive tract). A diagnosis of CIP is based on symptoms and body changes that occur when the intestine is blocked and surgery is needed. Children with CIP often complain of poor appetite, nausea, vomiting, heartburn, abdominal pain, and constipation. Affected children may not grow or develop at the expected rate. There is no specific test to diagnosis CIP. It is a diagnosis based on symptoms and findings after a physical examination, plus the proven absence of a true bowel obstruction. About 10 percent of affected infants improve spontaneously over months or years. For the remaining 90 percent, there are no cures for the neuromuscular diseases that cause CIP, but there are nutritional, medical, and surgical options to promote normal growth and development. The fact sheet briefly outlines each of these options. The fact sheet concludes that the future for children severely afflicted with CIP is brightened by the evolving promise of intestinal or multiorgan transplantation.
Major Descriptors (MJ): Digestive System Diseases. Children. Intestinal Pseudoobstruction. Diagnosis. Therapy.
Minor Descriptors (MN): Nutrition. Surgery. Diagnostic Tests. Symptoms. Gastrostomy. Supplemental Feeding. Child Development. Infants.
Verification/Update Date (VE): 199710.
Notes (NT): CP: Yes.
Accession Number (AN): DD DC 06047.

18. Stool Soiling in Children.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24). FACT SHEET (22).
Language(s) (LG): English.
Year Published (YR): 1997.
Audience code (AC): PATIENT (400).
Corporate Author (CN): American Academy of Family Physicians.
Source (SO): American Family Physician. 55(6): 2237-2238. May 1, 1997.
Abstract (AB): This patient information handout helps parents understand and manage stool soiling (messing the underwear with stool) in children. The author emphasizes that most often, the soiling occurs because of constipation (this type of soil is called encopresis). In children with encopresis, formed, soft, or liquid stools that often have a very bad smell leak from the anus around a mass of stool that is stuck in the lower bowel. The handout covers how stool soiling and constipation are related; the causes of constipation in a child; the treatment options for stool soiling; and how to know if the treatment is working. Treatment includes changing the child's diet to include more fluids and fiber-rich foods, having the child sit on the toilet several times a day, and giving the child laxatives every day to help soften the stools. The handout is designed to be photocopied and distributed by health care providers. (AA-M).
Major Descriptors (MJ): Digestive System Diseases. Children. Fecal Incontinence. Constipation. Patient Education. Parent Education. Patient Care Management.
Minor Descriptors (MN): Therapy. Cathartics. Drug Effects. Dietary Fiber. Diet Therapy. Fluids. Behavior Modification.
Verification/Update Date (VE): 199710.
Notes (NT): CP: Yes.
Accession Number (AN): DD DC 06061.

19. Pediatric Colonoscopy.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24).
Language(s) (LG): English.
Year Published (YR): 1997.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): Kay, M.; Wyllie, R.
Series (SE): (Pediatric Endoscopy Series, Article 3).
Source (SO): Practical Gastroenterology. 21(3): 7-8, 13-14, 19-20, 25-27. March 1997.
Availability (AV): Available from Shugar Publishing, Inc. 99B Main Street, Westhampton Beach, NY 11978. (631) 288-4404. Fax (631) 288-4435. E-Mail: info@practicalgastro.com.
Abstract (AB): This article, one in a series on pediatric endoscopy, considers the role of pediatric colonoscopy. Colonoscopy is now routinely performed in children with the use of intravenous conscious sedation or general anesthesia. The indications for pediatric colonoscopy differ from those for colonoscopy in adults. Rectal bleeding, protracted diarrhea, suspected polyps, and inflammatory bowel disease are the most common indications for colonoscopy in children. Colonoscopy is not useful in the evaluation of children with constipation and isolated recurrent abdominal pain. The technique of colonoscopy is modified for children, with emphasis on minimal loop formation and greater patient comfort during the procedure. Intubation of the terminal ileum is a standard part of the pediatric colonoscopy, and it is important for the diagnosis of Crohn's disease. Children require close monitoring for respiratory depression during colonoscopy. Resuscitation equipment of an appropriate size and pediatric dosages of medications should be available during endoscopic procedures. 8 figures. 18 references. (AA).
Major Descriptors (MJ): Digestive System Diseases. Children. Colonoscopy. Diagnostic Tests.
Minor Descriptors (MN): Diagnosis. Risk Factors. Patient Selection. Patient Care Management. Complications. Prevention. Crohns Disease. Gastrointestinal Bleeding. Inflammatory Bowel Disease. Polyps.
Verification/Update Date (VE): 200008.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 06008.

20. Gastrointestinal Hemorrhage in Children.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24).
Language(s) (LG): English.
Year Published (YR): 1997.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): Treem, W.R.
Series (SE): (Pediatric Endoscopy Series, Number 5).
Source (SO): Practical Gastroenterology. 21(7): 21-22, 27-32, 34-38. July 1997.
Availability (AV): Available from Shugar Publishing, Inc. 99B Main Street, Westhampton Beach, NY 11978. (631) 288-4404. Fax (631) 288-4435. E-Mail: info@practicalgastro.com.
Abstract (AB): This article, one in a series on pediatric endoscopy, summarizes the diagnostic approach to gastrointestinal hemorrhage in children. The author emphasizes that the approach to gastrointestinal bleeding in infants and children requires a knowledge of the special age-appropriate considerations that dictate the differential diagnosis. The routine application of five pivotal questions to each case will allow the physician to narrow the possibilities and focus on the most likely cause of bleeding. The questions are: Is it blood? What is the age of the patient? What is the color of the blood? Does the patient have diarrhea or constipation? and Is the patient sick? Careful history taking and physical examination will then determine the most expeditious route to a diagnosis using laboratory, radiologic, and endoscopic techniques. The author offers tips on the management of children with gastrointestinal bleeding, including the application of pharmacologic and endoscopic therapy to deal with bleeding varices, ulcers, and mucosal tears. 4 figures. 5 tables. 17 references. (AA-M).
Major Descriptors (MJ): Digestive System Diseases. Gastrointestinal Bleeding. Children. Infants. Diagnosis. Therapy.
Minor Descriptors (MN): Endoscopy. Diagnostic Tests. Hemorrhage. Symptoms. Drug Therapy. Gastric and Esophageal Varices. Ulcer. Mucosal Tissue. Physiopathology.
Verification/Update Date (VE): 200008.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 06118.

21. Chronic Intestinal Pseudo-Obstruction: A Guide for Parents-Caretakers.

Subfile: Digestive Diseases
Format (FM): BROCHURE/PAMPHLET (08).
Language(s) (LG): English.
Year Published (YR): 1997.
Audience code (AC): PATIENT (400).
Corporate Author (CN): American Pseudo-Obstruction and Hirschsprung's Disease Society, Inc.
Source (SO): North Andover, MA: American Pseudo-Obstruction and Hirschsprung's Disease Society, Inc. 1997. 4 p.
Availability (AV): Available from American Pseudo-Obstruction and Hirschsprung's Disease Society, Inc. 158 Pleasant Street, North Andover, MA 01845. (978) 685-4477. Fax (978) 685-4488. E-mail: aphs@tiac.net. PRICE: Single copy free.
Abstract (AB): This brochure provides basic information for parents and other caregivers of children with chronic intestinal pseudo-obstruction (CIP) and other forms of chronic gastrointestinal (GI) motility disorder. GI motility refers to the muscle contractions within the walls of the digestive tract and the movement of food within the digestive system. Written in question and answer format, the brochure addresses the causes of GI motility disorders, the definition and cause of CIP, the incidence and diagnosis of CIP, treatment options, enteral feeding, parenteral feeding, and the impact of CIP on the child's development and lifespan. In pseudo-obstruction, the symptoms are not caused by a surgically correctable tumor, or twist or ulcer in the bowel, but rather by a problem having to do with the strength or coordination of the contractions that move along contents within the bowel. Children with CIP often complain of poor appetite, nausea, vomiting, heartburn, abdominal pain, and constipation. As a result, normal growth and development may be affected. One treatment option, enteral feedings, consists of predigested liquid diets which may be administered in a variety of ways, including nasogastric tubes, gastrostomy, or jejunostomy. Another option is total parenteral nutrition (TPN), in which a nutritional solution is infused via an intravenous access. The brochure concludes with a brief description of the American Pseudo-obstruction and Hirschsprung's Disease Society (APHS), a group that offers support and information through parent networking, publications, and educational activities.
Major Descriptors (MJ): Digestive System Diseases. Intestinal Pseudoobstruction. Children. Diagnosis. Symptoms. Therapy. Nutrition. Motility Disorders.
Minor Descriptors (MN): Child Development. Etiology. Parent Education. Support Groups. Gastrostomy. Enteral Nutrition. Parenteral Nutrition. Gastrointestinal Motility.
Verification/Update Date (VE): 199807.
Notes (NT): CP: Yes.
Accession Number (AN): DD BR 06544.

22. Recommendations of Various Authors Regarding Pediatric Dosing of Cisapride (Propulsid).

Subfile: Digestive Diseases
Format (FM): FACT SHEET (22).
Language(s) (LG): English.
Year Published (YR): 1997.
Audience code (AC): HEALTH PROFESSIONALS (100).
Corporate Author (CN): Children's Motility Disorder Foundation.
Source (SO): Atlanta, GA: Children's Motility Disorder Foundation. 1997. 2 p.
Availability (AV): Available from Children's Motility Disorder Foundation. 225 Peachtree Street, NE, Suite 1430, Atlanta, GA 30303. (800) 809-9492 or (404) 529-9200. Fax (404) 529-9202. E-mail: cmdf@motility.org. PRICE: Single copy free.
Abstract (AB): This fact sheet consists of a chart that summarizes the recommendations of various authors regarding pediatric dosing of cisapride (Propulsid). The fact sheet reminds readers that Propulsid is not approved by the U.S. Food and Drug Administration (FDA) for pediatric use. Therefore, a safe and effective pediatric dose has not been established. The chart lists the researchers of each study, the therapeutic area covered, the age of children in the study, and the dosage of cisapride used. Therapeutic areas include reflux (gastroesophageal reflux disease), pseudoobstruction, intractable constipation, cystic fibrosis, reflux associated with bronchopulmonary disease, and excessive regurgitation. Dosages ranged from 0.1 to 0.33 mg per kilogram of body weight, three times per day (t.i.d.). The reverse side of the fact sheet lists the bibliographic references for each of the eleven research studies listed, as well as for two review articles on this topic.
Major Descriptors (MJ): Digestive System Diseases. Children. Drug Therapy. Gastroesophageal Reflux Disease. Motility Disorders.
Minor Descriptors (MN): Intestinal Pseudoobstruction. Cystic Fibrosis. Constipation. Drug Effects. Administration and Dosage. Research. Gastrointestinal Motility.
Verification/Update Date (VE): 199807.
Notes (NT): CP: Yes.
Accession Number (AN): DD DC 06504.

23. Constipation and Encopresis in Children.

Subfile: Digestive Diseases
Format (FM): FACT SHEET (22).
Language(s) (LG): English.
Year Published (YR): 1997.
Audience code (AC): PATIENT (400).
Author (AU): Scagnelli, G.
Source (SO): Milwaukee, WI: International Foundation for Functional Gastrointestinal Disorders (IFFGD). 1997. 2 p.
Availability (AV): Available from International Foundation for Functional Gastrointestinal Disorders (IFFGD). P.O. Box 170864, Milwaukee, WI 53217. (888) 964-2001 or (414) 964-1799. Fax (414) 964-7176. E-mail: iffgd@iffgd.org. Website: www.iffgd.org. PRICE: $0.50 plus shipping and handling; bulk copies available. Order number: 140.
Abstract (AB): Constipation or encopresis account for approximately 10 to 25 percent of children who are referred to a pediatric gastroenterologist. This fact sheet reviews the problems of constipation and encopresis (involuntary fecal soiling) in children. The fact sheet first describes the diseases with which the symptom of constipation is associated, also noting the role of diet and evacuation habits in the etiology of constipation problems. All children with constipation, but especially those with encopresis, should be evaluated by their physicians. Evaluation may include a thorough physical examination; blood work to include thyroid, calcium, and lead level; and sometimes a barium enema and anal manometry. Treatment of constipation usually involves two steps. First, enemas are required if there is a stool mass in the rectum. The next step is to use oral medicines to ensure a soft daily bowel movement. Stool softeners, such as mineral oil or lactulose, are frequently used. Diet also plays an important role in the treatment of constipation. Since many of the children in whom constipation is a problem do not have normal rectal sensation, they must be encouraged to sit on the toilet at least two times a day. The best time to sit on the toilet is after a meal, usually after breakfast and after dinner. The fact sheet stresses that by the time constipation is perceived as a problem it has usually been going on for some time. Treatment will take time and patience to be effective.
Major Descriptors (MJ): Digestive System Diseases. Children. Constipation. Fecal Incontinence. Symptoms. Therapy.
Minor Descriptors (MN): Etiology. Diet Therapy. Dietary Fiber. Enema. Impacted Feces. Drug Therapy. Behavior Modification. Parent Education.
Verification/Update Date (VE): 200011.
Notes (NT): CP: Yes.
Accession Number (AN): DD DC 06834.

24. Colon Manometry.

Subfile: Digestive Diseases
Format (FM): NEWSLETTER ARTICLE (35).
Language(s) (LG): English.
Year Published (YR): 1997.
Audience code (AC): PATIENT (400).
Corporate Author (CN): American Pseudo-obstruction and Hirschsprung's Disease Society (APHS).
Source (SO): Messenger. 8(3): 8. 1997.
Availability (AV): Available from American Pseudo-obstruction and Hirschsprung's Disease Society (APHS). 158 Pleasant Street, North Andover, MA 01845. (978) 685-4477. Fax (978) 685-4488. E-mail: aphs@tiac.net.
Abstract (AB): This newsletter article uses a fact sheet approach to explain colon manometry to the parents of children who may be undergoing this procedure. Written in a question and answer format, the fact sheet covers gastrointestinal motility problems in general, the technique of colon manometry, what to expect during the procedure (including pain or discomfort), and how long the procedure takes. Gastrointestinal motility is the movement of the food through the entire digestive tract (about 30 feet from the mouth to the rectum). Common examples of symptoms related to motility problems are heartburn and constipation. The strength of muscle contractions inside the colon are measured during colonic manometry. Colon manometry is the measurement of pressure in the colon. The test may be used to help doctors understand the reasons for a child's symptoms. During the procedure, the child is sedated and then a colonoscope (a flexible plastic tube) is inserted into the colon through the rectum. Next, a very thin guidewire is placed through the colonoscope, and the colonoscope is withdrawn, leaving the guidewire in the colon. The doctor will then slide a motility tube over the guidewire, which is subsequently removed. The motility tube has holes at regular spaces that measure the pressure in different areas of the colon. The colon manometry may last as little as 90 minutes or as long as 8 hours. The child must lie in bed, but he or she can sleep, read, or watch television; parents are allowed to stay. The child will feel some discomfort from the IV (for the sedation), from lying still for a long period, and possibly from injections of medicine. 4 figures.
Major Descriptors (MJ): Digestive System Diseases. Diagnostic Tests. Colon. Manometry. Gastrointestinal Motility. Children.
Minor Descriptors (MN): Colonoscope. Motility Disorders. Diagnosis. Physiology. Symptoms. Equipment and Supplies.
Verification/Update Date (VE): 199910.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 07128.

25. Biofeedback Training in Children with Functional Constipation: A Critical Review.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24). REVIEW (46).
Language(s) (LG): English.
Year Published (YR): 1996.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): Loening-Baucke, V.
Source (SO): Digestive Diseases and Sciences. 41(1): 65-71. January 1996.
Abstract (AB): This article reviews the use of biofeedback training in children with functional constipation. Many uncontrolled studies suggest that biofeedback training is an effective adjunctive therapy in improving the outcome of functional constipation and/or encopresis in children. This could not be confirmed in controlled studies. Adding biofeedback training after conventional treatment had failed did not provide benefits. The author concludes that the results of biofeedback treatment in children with functional constipation and/or encopresis are disappointing. 1 figure. 2 tables. 31 references. (AA-M).
Major Descriptors (MJ): Digestive System Diseases. Fecal Incontinence. Children. Biofeedback.
Minor Descriptors (MN): Research. Therapy. Physiology. Behavior Modification.
Verification/Update Date (VE): 199607.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 05327.

26. Current Management of Childhood Disorders of Colorectal Motility.

Subfile: Digestive Diseases
Format (FM): JOURNAL ARTICLE (24). REVIEW (46).
Language(s) (LG): English.
Year Published (YR): 1996.
Audience code (AC): HEALTH PROFESSIONALS (100).
Author (AU): O'Donnell, K.A.; Caty, M.G.
Series (SE): (Large Intestine).
Source (SO): Current Opinion in Gastroenterology. 12(1): 18-25. January 1996.
Availability (AV): Available from Rapid Science Publishers. 400 Market Street, Suite 700, Philadelphia, PA 19106. (215) 574-2266. Fax (215) 574-2292.
Abstract (AB): This article reviews the current management of childhood disorders of colorectal motility. A number of motility disorders in children are associated with intestinal neuronal malformations and other anatomic defects. These disorders include Hirschsprung's disease, neuronal intestinal dysplasia, chronic intestinal pseudo-obstruction, and anorectal malformations. Hirschsprung's disease is now linked to specific genetic mutations, and laparoscopic techniques hold promise for less invasive surgical treatment. Neuronal intestinal dysplasia is now considered an important cause of postoperative bowel dysfunction in Hirschsprung's disease patients. Chronic intestinal pseudo-obstruction is characterized by recurrent bouts of abdominal distension, pain, and constipation. The surgical treatment of these patients is relegated to the placement of feeding and decompression tubes. For the past decade, posterior sagittal anorectoplasty has been the preferred approach in the repair of anorectal malformations. Long-term assessments of bowel function after the use of this procedure are now being published and show generally good outcome. 2 figures. 57 references (34 annotated).
Major Descriptors (MJ): Digestive System Diseases. Children. Motility Disorders. Gastrointestinal Motility. Diagnosis. Therapy.
Minor Descriptors (MN): Hirschsprung Disease. Anorectal Disease. Abnormalities. Surgery. Surgical Techniques. Intestinal Pseudoobstruction. Symptoms. Review.
Verification/Update Date (VE): 199610.
Notes (NT): CP: Yes.
Accession Number (AN): DD JA 05434.

27. What Every Parent Should Know About Toilet Training.

Subfile: Digestive Diseases
Format (FM): BROCHURE/PAMPHLET (08).
Language(s) (LG): English.
Year Published (YR): 1996.
Audience code (AC): PATIENT (400).
Corporate Author (CN): Channing L. Bete Company, Inc.
Source (SO): South Deerfield, MA: Channing L. Bete Company, Inc. 1996. 15 p.
Availability (AV): Available from Channing L. Bete Company, Inc. 200 State Road, South Deerfield, MA 01373-0200. (800) 628-7733. Fax (800) 499-6464. PRICE: $1.25 each for 1-24 copies; discounts available for larger orders.
Abstract (AB): This patient education booklet provides parents with guidelines for helping their children with toilet training. After a definition of toilet training and a rough guide as to when to expect toilet training to succeed, the booklet covers steps toward independence for the child; the developmental stages that must be completed before a child can succeed in toileting regularly; the basics of toilet training; signs of readiness for toilet training; changing from diapers to training pants; readiness for nighttime training; common toilet training issues; and problems with constipation. Parents are encouraged to make toilet training a positive experience for their children. The booklet is illustrated with cartoon line drawings of children and their families.
Major Descriptors (MJ): Digestive System Diseases. Psychosocial Factors. Patient Education. Self-Care. Children.
Minor Descriptors (MN): Emotions. Fecal Incontinence. Constipation. Parent-Child Relations.
Verification/Update Date (VE): 199701.
Notes (NT): CP: Yes.
Accession Number (AN): DD BR 05621.

28. When Your Child is Constipated.

Subfile: Digestive Diseases
Format (FM): FACT SHEET (22). JOURNAL ARTICLE (24).
Language(s) (LG): English.
Year Published (YR): 1996.
Audience code (AC): PATIENT (400).
Corporate Author (CN): American Academy of Family Physicians.
Source (SO): American Family Physician. 54(2): 627. August 1996.
Abstract (AB): This patient education handout helps parents manage their child's constipation. Three sections discuss symptoms; causes; and management options, including diet, bowel habit training, and drug therapy. The handout is designed to be photocopied and distributed to parents by health care providers.
Major Descriptors (MJ): Digestive System Diseases. Constipation. Children. Parent Education.
Minor Descriptors (MN): Patient Education. Diet Therapy. Drug Therapy. Fluids. Dietary Fiber. Behavior Modification.
Verification/Update Date (VE): 199701.
Notes (NT): CP: Yes.
Accession Number (AN): DD DC 05643.

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Comment in:

Botulinum toxin for chronic anal fissure.

Gui D, Cassetta E, Anastasio G, Bentivoglio AR, Maria G, Albanese A.

Istituto di Clinica Chirurgica, Universita Cattolica del Sacro Cuore, Roma, Italy.

Botulinum toxin can chemically denervate striated muscle. Botulinum toxin A (15 U) was used to treat ten patients with chronic anal fissure by injection in the internal sphincter. In seven patients, the lesion healed at 2 months after treatment; one relapsed at 3 months. In one patient the lesion healed at 1 month, but partly relapsed a month later. Mild faecal incontinence lasting for 1 day was observed in one patient. We propose that botulinum toxin injections in the internal anal sphincter be considered an alternative approach to surgical therapy of anal fissure.

Publication Types:
  • Clinical Trial

PMID: 7934496 [PubMed - indexed for MEDLINE]

ANAL FISSURE -- BOTOX

Updated -- October 2001

Introduction

An anal fissure, or split in the skin of the distal anal canal, is a common problem that causes substantial morbidity in people who are otherwise healthy. The incidence of anal fissure is similar in men and women.

The majority of fissures occur in the posterior midline of the anal canal and are usually the result of tearing of the skin from hard stool or other physical irritants. Multiple fissures or lateral fissures may have other causes, such as Crohn's disease, ulcerative colitis, tuberculosis,infection with human immunodeficiency virus (HIV) or syphilis.

Spasm of the anal sphincter has been noted in association with anal fissure, and for many years treatment has focused on alleviating spasm of the sphincter. Since 1951, the most common treatment for chronic anal fissure in the United States and Europe has been lateral internal sphincterotomy. This involves cutting the internal sphincter on the right or left mid-lateral area to break the circular anatomy of the muscle permanently.

Although the technique is simple and effective, the fundamental drawback of this surgery is its potential to cause minor but sometimes permanent alterations in the control of gas, mucus and, occasionally, stool. This can sometimes become a major problem, particularly in elderly patients or those with diarrhea, irritable bowel syndrome, diabetes or recurrent fissure after previous surgery.

Management without Surgery

Initial medical management in the office consists of keeping the stools soft to avoid tearing the anal skin, frequent sitz baths to increase local blood flow and relax the sphincter, and topical steroid-anesthetic medications to decrease the inflammatory response and to provide local anesthesia. The goal of medical therapy is to create the effect of a temporary or reversible sphincterotomy, reducing sphincter pressure only until the fissure has healed.

Surgical Intervention

If this fails after a reasonable treatment duration, the next step has traditionally been surgical intervention with a lateral internal sphincterotomy, with or without removing the fissure itself.

Recently, two new medical modalities have been investigated to provide another level of medical therapy before undergoing surgical intervention.Because they have only a temporary effect, they avoid the risk of permanent injury to the internal anal sphincter. A reduction of the anal pressure for three or more months usually allows the fissure to heal and thus eliminates the need for surgery.

First is the topical application of dilute nitroglycerin paste to produce local relaxation of the exposed smooth muscle of the anus. While this helps relax the sphincter, it does not dramatically promote healing.In addition, it produces incapacitating headaches in many patients.Therefore, it has not turned out to be the new treatment of choice.

The other new modality is the local injection of 20 units of Botulinum toxin (Botox) into the area of the internal anal sphincter. Botox causes denervation of the internal anal sphincter. The toxin acts rapidly and paralysis occurs within a few hours. Weakening of the muscle is seen clinically for three to four months. This reduction in the resting pressure of the anal muscle produces the equivalent of a surgical lateral internal sphincterotomy and thus allows the fissure to heal.

Various healing rates with the toxin injection have been reported to vary from 60 to 90 percent after two to three months. A second injection is possible.

Risks

Complications have been uncommon. Fecal or mucous leakage has been reported in less than one percent of cases. Leakage, when it occurs, is both minimal and temporary. Pain, infections or other local problems at the injection site have not been recorded.

Although the Botox injection seems to be a very safe procedure at this time, it may be too early in the world of clinical experience to really know what the overall rate of healing and complications will be after several years of widespread use. Because of this, PAMF does not recommend using Botox as the initial treatment of a fissure but reserves it for the treatment of fissures that fail to heal after a reasonable trial of more conservative measures 

 

Published Laser Research


Dis Colon Rectum 1995 Dec;38(12):1265-9 Related Articles

Ambulatory hemorrhoidectomy with CO2 laser.

Hodgson WJ, Morgan J.

Section of Gastro-Intestinal and Colo-Rectal Surgery, Westchester Medical Center, Valhalla, New York, USA.

PURPOSE: This study was undertaken to evaluate ambulatory hemorrhoidectomy using the CO2 laser. METHODS: Ninety consecutive patients (50 males, 40 females), 80 percent of whom had second or third degree hemorrhoids, had ambulatory hemorrhoidectomy performed with a CO2 laser in the left lateral Sims position under local anesthesia and intravenous sedation. Dissection was entirely performed with the CO2 laser using an open technique. RESULTS: One patient with polycythemia vera was admitted subsequently for secondary hemorrhage. All but three patients had healed within four weeks. No long-term sequelae were encountered. CONCLUSION: These results compare favorably with those obtained by others and show that ambulatory laser hemorrhoidectomy may simplify management in selected patients.


J Chir (Paris) 1990 Apr;127(4):227-9

[Outpatient hemorrhoidectomy using the CO2 laser]

Masson JL.

In the free standing center of ambulatory surgery of Nice, proctology with carbon dioxide laser is a basic activity. Among 177 cases of proctology operated during 1989, we find 91 hemorrhoidectomies realized with CO2 laser in strictly ambulatory surgery (no hospitalization). This work's interet is demonstrating adaptation to the laser makes many advantages to the classic operation of Milligan and Morgan: simplification of the surgical technique easy post-operative course, no hospitalization and quicker return to work, leading to a lower cost of this pathology. Complications are rare and excellent results noted.


Dis Colon Rectum 1991 Jan;34(1):78-82

The role of lasers in hemorrhoidectomy.

Wang JY, Chang-Chien CR, Chen JS, Lai CR, Tang RP

Department of Surgery, Chang Gung Memorial Hospital Taipei, Taiwan.

Abstract: Laser hemorrhoidectomy patients had less pain, less constipation, less urinary retention, and spent less time in the hospital than traditional hemorrhoidectomy patients.

Eighty-eight patients who received treatment for hemorrhoids were randomized into two groups. Group A received the Nd-YAG laser phototherapy for internal hemorrhoid combined with the CO2 laser for external hemorrhoid. Group B was treated with closed Ferguson hemorrhoidectomy. The need of narcotic injections for pain relief was 11 percent in group A vs. 56 percent in group B (P less than 0.001). The incidence of postoperative urinary retention was 7 percent in group A, vs. 39 percent in group B (P less than 0.05). No enema was required postoperatively in group A, vs. 9 percent in group B; 84 percent of the patients in group A were discharged on the second postoperative day, vs. 83 percent of the patients in group B discharged on the fifth postoperative day. The cost was 20 percent less in the former group.


Jpn J Surg 1989 Nov;19(6):658-61

The laser treatment of hemorrhoids: results of a study on 1816 patients.

Iwagaki H, Higuchi Y, Fuchimoto S, Orita K

Higuchi General Hospital, Okayama, Japan.

Laser is an effective, simple and harmless clinical procedure used for the treatment of hemorrhoids, as an alternative to medical therapy or surgery. In this report, we describe our experience of applying carbon dioxide laser to hemorrhoids in a total 1816 consecutive patients. The results lead us to conclude that the laser treatment of hemorrhoids is effective in pain alleviation from the first session and that patients so treated have a much more comfortable postoperative course.


Vestn Khir Im I I Grek 1989 Sep;143(9):3-5

[Carbon dioxide laser in the surgical treatment of proctologic diseases]

Skobelkin OK, Tolstykh PI, Derbenev VA, Ste'nko VG, Kochurkov NV.

Results of the surgical treatment of 556 patients with different diseases of the anorectal area with the help of CO2 laser are presented. Functional results were good, the amount of postoperative complications was 1.5 times less, recurrences were half less, the time of intrahospital treatment was 1.5 day shorter, the period of ambulatory rehabilitation 3.8 days shorter.


Int J Colorectal Dis 1995;10(1):22-4

CO2 laser haemorrhoidectomy--does it alter anorectal function or decrease pain compared to conventional haemorrhoidectomy?

Chia YW, Darzi A, Speakman CT, Hill AD, Jameson JS, Henry MM

Department of Surgery, Central Middlesex Hospital, London, UK.

Carbon dioxide (CO2) laser haemorrhoidectomy is feasible and safe provided it is used with care. It is associated with a reduced requirement for post-operative analgesia. The CO2 laser caused no significant alteration in anorectal physiology.


http://www.slti.com/hemorrhoid.html, 1998-99

Dr. Gerald Kirshenbaum, Aurora, CO and Dr. Allen Snyder, Pittsburgh, PA

It is a simple, rapid, and remarkably effective procedure. These doctors report that the procedure is significantly shorter with the Contact Laser technique, taking approximately 20 minutes for one large hemorrhoid and about 45 minutes for three. Following cold knife, electrocautery, or non-contact laser hemorrhoidectomy, patients typically remain in the hospital for 3-5 days and leave in considerable discomfort. Following Contact Laser hemorrhoidectomy, the typical patient will return home the same day, by 3 or 4 days they are moving their bowels without undue pain or difficulty, and they can return to their normal routine by 7-10 days post-operatively.

Both physicians find a marked difference in pain compared to traditional techniques. Though it is not clear which aspects of the procedure are responsible for this reduction in post-surgical symptoms, the total procedure using this technique appears to have a positive impact on the patient's recovery. There is less tissue damage and muscle stimulation than with other methods, the laser seals lymphatics so that there is markedly less edema, and there is some belief that the laser energy may also seal nerve endings.

Anal Fissure, Abscess and Fistula

The anal canal final section of digestive tract, from 2.5 to 4 cm (1 to 1.6 inches) in length, emptying through the anus, along of this pathway the anatomy and histology change, and several anatomical part are caused of  several condition. Usually involves only the epithelium and, in the long-term, involves the full thickness of the anal mucosa

 Several condition and dysfunction can be seen , caused by various condition and situation from hemorrhoids [vein problem] , inflammation and infection, ulceration [fissure] and other condition  considered congenital as prolapse rectum check for cystic fibrosis. But in this part we will emphasis only on the anal fissure and fistula.

Anal Fissure

A crack in the tissue, just imagine putting two enormous force in two side of your skin or antrhing else as matter, what happen there is a rupture, the same phenomena occur in here .An anal fissure is a painful linear tear or crack in the distal anal canal, which, in the short-term, usually involves only the epithelium and, in the long-term, involves the full thickness of the anal mucosa

THE MOST COMMON CAUSE HERE BEING CONSTIPATION AND HARD FECES[THIS IS WHY WE ASK THOSE CONSIPATED TO DRINK A LOT OF FLUIDS]  . BUT HARD FECES AND CONSTIPATION IS NOT THE ONLY CAUSE THE REVERSE CAN BE ALSO THE CAUSE MEANING DIARRHEA, AND SOME INFLAMMATORY CONDITION MAKING THE AREA HYPERSTIMULATED AND WEAKER CAUSING THE FISSURE ALSO.

Most anal fissures arise following trauma (injury) to the anus. The commonest trauma is that occasioned by the passage of a hard constipated stool ok we said that already . However, anal fissures can , childbirth or any other type of injury . An anal fissure is a simple mechanical problem and does not "turn to cancer".

Plate 10.208 Rectum and Anal CanalRectum and Anal Canal  Ronald A. Bergman, Ph.D., Adel K. Afifi, M.D., Paul M. Heidger, Jr., Ph.D.

It start by a small split in the lower third of the anal canal. This split fails to heal and becomes established as a painful longitudinal ulcer associated with spasm of the anal sphincter muscle. Pain [very painful in some cases especially during and immediately following bowel movements ] is the major symptom of anal fissure.

It comes on at the time of defecation and lasts for a variable period afterwards. It is mainly due to intense spasm in the internal anal sphincter muscle. Bleeding is a commonly associated symptom, especially when the fissure first develops. An anal lump may be noted. This may be a swollen skin tag associated with the fissure

he most commonly observed abnormalities are hypertonicity and hypertrophy of the internal anal sphincter, leading to elevated anal canal and sphincter resting pressures. The internal sphincter maintains the resting pressure of the anal canal, and anal-rectal manometry can be used to measure this pressure. Most patients with anal fissures have an elevated resting pressure, and this resting pressure returns to normal levels after surgical sphincterotomy

 

The posterior anal commissure is the most poorly perfused part of the anal canal. In patients with hypertrophied internal anal sphincters, this delicate blood supply is further compromised, thus rendering the posterior midline of the anal canal relatively ischemic.

This is thought to account for why many fissures do not heal spontaneously and may last for several months. Pain accompanies each bowel movement as this raw area is stretched and the injured mucosa is abraded by the stool. The internal sphincter also begins to spasm when a bowel movement is passed, which has 2 effects. First, the spasm itself is painful; second, the spasm further reduces the blood flow to the posterior midline and the anal fissure, contributing to the poor healing rate.

 

Histologic Findings: The fissure is not usually excised; therefore, no pathology specimen is available for examination. When it is excised, the tissue typically exhibits nonspecific inflammation. If some of the muscle is accidentally excised with the fissure, the internal sphincter usually demonstrates fibrosis.

 

 

Pathophysiology: .

Clinical: Typically, the symptoms of an anal fissure are relatively specific, and the diagnosis can often be made based on history findings alone. The patient reports severe pain during a bowel movement, with the pain lasting several minutes to hours afterward. The pain recurs with every bowel movement, and the patient commonly becomes afraid or unwilling to have a bowel movement, leading to a cycle of worsening constipation, harder stools, and more anal pain. Approximately 70% of patients note bright red blood on the toilet paper or stool. Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure.

Initially, the fissure is just a tear in the anal mucosa and is defined as an acute anal fissure. If the fissure persists over time, it progresses to a chronic fissure that can be distinguished by its classic features. The fibers of the internal anal sphincter are visible in the base of the chronic fissure, and often, an enlarged anal skin tag is present distal to the fissure and hypertrophied anal papillae are present in the anal canal proximal to the fissure.

Most anal fissures occur in the posterior midline, with the remainder occurring in the anterior midline (99% of men, 90% of women). Two percent of patients have both anterior and posterior fissures. Fissures occurring off the midline should raise the possibility of other etiologies (eg, Crohn disease), an infectious etiology (eg, sexually transmitted disease, AIDS), or cancer

Failure of medical therapy to resolve the acute fissure is an indication for surgical intervention. The presence of a symptomatic chronic fissure is also an indication for surgery because few of these heal spontaneously

 

The exact etiology of anal fissures is unknown, but the initiating factor is thought to be trauma from the passage of a particularly hard or painful bowel movement. Low-fiber diets, such as those lacking in raw fruits and vegetables, are associated with the development of anal fissures. No occupations are associated with a higher risk for the development of anal fissures. Prior anal surgery is a predisposing factor because scarring from the surgery may cause either stenosis or tethering of the anal canal, which makes it more susceptible to trauma from hard stool.

Initial minor tears in the anal mucosa due to a hard bowel movement probably occur often, and, in most people, these heal rapidly without long-term sequelae. In patients with underlying abnormalities of the internal sphincter, these injuries progress to acute and chronic anal fissures. Studies of the internal anal sphincter and of anal canal physiology have been performed with varied results, but at least one abnormality is likely present in the internal anal sphincter of many anal fissure patients.

  • Along with a history, the diagnosis can usually be made based on findings from a gentle perianal examination with inspection of the anal mucosa. In this case, no diagnostic procedures are required. A digital rectal examination is painful and often can be deferred.
    • Occasionally, the fissure is not easily visualized, and anoscopy is required to see it. However, this is not well tolerated by a patient with an acute anal fissure, and anoscopy can often be deferred and the patient treated based on symptoms only. Occasionally, a topical application of 1-2% lidocaine facilitates the examination.
    • Patients who do not heal, those who have relief from symptoms with appropriate therapy, or those who have a recurrent anal fissure after surgical therapy should be evaluated further with anoscopy and rigid proctosigmoidoscopy to exclude other pathologies. Patients with chronic fissures tend to have less pain and can better tolerate either anoscopy or rigid proctosigmoidoscopy and should have this included in their evaluation.

Diagnosis
A simple visual examination of the anus and surrounding tissue usually reveals the fissure. It is quite tender when examined by the physician. Fissures are most often located in the middle posterior (back) section of the anus.

Treatment

Treat the cause first and not the symptoms

Anal canal

The anal canal has 2 definitions. The first is the functional or surgical anal canal, and the second is the anatomic anal canal. The terms are often used interchangeably, even though they do not mean the same thing. The surgical anal canal is approximately 4 cm long and extends from the anal verge or intersphincteric groove distally to the anorectal ring proximally. The anatomic anal canal is only approximately 2 cm long and extends from the anal verge distally to the dentate line proximally.

Anal verge

The anal verge is an anocutaneous line approximately 2 cm distal to the dentate line. The anal verge marks the beginning of the anal canal.

Dentate line

The dentate line is the junction of the ectoderm and endoderm in the anal canal.

Internal anal sphincter

The internal anal sphincter is a smooth muscle that is the most distal extension of the inner circular smooth muscle of the colon and the rectum. It is 2.5-4 cm long and is normally 2-3 mm thick. The internal sphincter is not under voluntary control and is continuously contracted to prevent unplanned loss of stool.

External anal sphincter

The external anal sphincter is striated muscle that forms a circular tube around the anal canal. Proximally, it merges with the puborectalis muscle and the levator ani to form a single complex. Control of the external anal sphincter is voluntary.

Contraindications: The main contraindication to surgery for an anal fissure is impaired fecal continence because this could be worsened with surgery. This contraindication mostly applies to patients with minor incontinence (occasional seeping). Patients with gross fecal incontinence (solid material) rarely develop fissures; however, those with irritable bowel syndrome and incontinence to liquid stool can develop fissures if they become constipated. These patients are at the most risk for surgical treatment of an anal fissure because their typical bowel pattern is loose and more difficult to control.

Medical Treatment

About 50% of anal fissures heal without the need for surgery. Many acute superficial fissures heal spontaneously. Even deep chronic fissures can heal with conservative measures of dietary management (regular meals with increased fibre content), use of stool bulking agents (such as Agiofibe, Normacol or Metamucil), and frequent warm baths. If the anal fissure is to heal this should occur within a few weeks. Recurrence of the fissure months or years later may occur.

Surgical Treatment

The surgical treatment of an anal fissure can usually be performed as a day procedure with minimal hospital stay. The usual operation is "sphincterotomy" which is done under anaesthesia. This operation involves a small cut near the anal opening, with the division of the lowest part of the internal anal sphincter muscle. The fissure itself may not be removed. The spasm is relieved and the fissure is then able to heal. Any large or troublesome skin tag related to the fissure is removed.

Results

Prompt relief from the pain is to be expected, even though healing of the fissure may take some weeks. In a small number of people (about 5%) the fissure does not heal and the sphincterotomy may need to be repeated. Once surgical cure has been achieved less than 10% of people will develop another fissure.

Complications Of Surgery

These are very uncommon as the operation is simple and safe. Rarely there may be post operative bleeding. In approximately 5% of patients the healing of the wounds may be delayed.

Anal Sphincter Function After Surgery

The small incision in the internal anal sphincter (sphincterotomy) may result in a slight imperfection in the control of "wind" in the rectum. This is usually a temporary problem. Incontinence of faeces (loss of control of bowel movement) is an extremely rare complication..

Medical therapy: Initial therapy for an anal fissure is medical in nature, and more than 80% of acute anal fissures resolve without further therapy. The goals of treatment are to relieve the constipation and to break the cycle of hard bowel movement, associated pain, and worsening constipation. Softer bowel movements are easier and less painful for the patient to pass.

First-line medical therapy consists of therapy with stool-bulking agents, such as fiber supplementation and stool softeners. Laxatives are used as needed to maintain regular bowel movements. Mineral oil may be added to facilitate passage of stool without as much stretching or abrasion of the anal mucosa, but it is not recommended for indefinite use. Sitz baths after bowel movements and as needed provide significant symptomatic relief because they relieve some of the painful internal sphincter muscle spasm. Recurrence rates range from 30-70% if the high-fiber diet is abandoned after the fissure is healed. This rate can be reduced to 15-20% if patients remain on a high-fiber diet.

Second-line medical therapy is the topical application of 0.2% nitroglycerin (NTG) ointment directly to the internal sphincter. Some physicians use NTG ointment as initial therapy in conjunction with fiber and stool softeners, and others prefer to add it to the medical regimen if fiber and stool softeners alone fail to heal the fissure. NTG ointment is thought to relax the internal sphincter and to help relieve some of the pain associated with sphincter spasm; it also is thought to increase blood flow to the anal mucosa.

Unfortunately, many people cannot tolerate the adverse effects of NTG, often limiting its use. The main adverse effects are headache and dizziness; therefore, instruct patients to use NTG ointment for the first time in the presence of others or directly before bedtime.

The efficacy of NTG ointment has been debated in many studies, and its use is still controversial. NTG ointment is specially mixed at this lower concentration and is available only in pharmacies that specially make it. Analogous to the use of NTG ointment, nifedipine ointment is also available for use in clinical trials. It is thought to have similar efficacy to NTG ointment but with fewer adverse effects.

A newer therapy for acute and chronic anal fissures is botulinum toxin (Botox). The toxin is injected directly into the internal anal sphincter and, in effect, performs a chemical sphincterotomy. The effect lasts approximately 3 months, until the nerve endings regenerate. This 3-month period may allow acute fissures (and sometimes chronic fissures) to heal and symptoms to resolve. Initial relief of symptoms with Botox injection but recurrence after 3 months suggests that the patient would benefit from surgical sphincterotomy.

Surgical therapy: Surgical therapy is usually reserved for acute anal fissures that remain symptomatic after 3-4 weeks of medical therapy and for chronic anal fissures.

Preoperative details: Two Fleet enemas the morning of surgery is sufficient bowel preparation for this procedure. If the anal fissure is too painful, the enemas may be omitted. No other preoperative preparation is necessary unless the patient has significant comorbidities that require attention.

Intraoperative details:

Sphincter dilatation

This procedure is a controlled anal stretch or dilatation under general anesthetic. This is performed because one of the causative factors for anal fissure is thought to be a tight internal anal sphincter; stretching it helps correct the underlying abnormality, thus allowing the fissure to heal. The number of fingers used and the amount of time the stretch is applied varies among surgeons. While the sphincter stretch does provide symptomatic relief from the anal fissure, it is rarely performed today because of the high complication rate. Impaired continence is observed in 12-27% of patients because of the uncontrolled stretching and subsequent tearing of both the internal and external sphincter.

Lateral internal sphincterotomy

This is the current surgical procedure of choice. The procedure can be performed with the patient under general or spinal anesthesia. (Local anesthesia may even be used in the cooperative patient, although this is not always recommended). The purpose of an internal sphincterotomy is to cut the hypertrophied internal sphincter, thereby releasing tension and allowing the fissure to heal.

When first described, the sphincterotomy was performed in the posterior midline at the site of the fissure with or without a fissurectomy. However, the incision for the sphincterotomy usually did not heal for exactly the same reason that the fissure did not heal. Now, sphincterotomies are normally performed in the lateral quadrants (right or left, depending on the comfort or handedness of the surgeon). In a properly performed lateral internal sphincterotomy, only the internal sphincter is cut; the external sphincter is not cut and must not be injured.

The sphincterotomy can be performed in either an open or a closed manner. In a closed sphincterotomy, a No. 11 blade is inserted sideways into the intersphincteric groove laterally. It is then rotated medially and drawn out to cut the internal sphincter. Care is taken to not cut the anal mucosa because this could result in a fistula. After the knife is removed, the anal mucosa overlying the sphincterotomy is palpated, and a gap in the internal sphincter can be felt through it. The sphincterotomy is extended into the anal canal for a distance equal to the length of the anal fissure.

In an open sphincterotomy, a 0.5- to 1-cm incision is made in the intersphincteric plane. The internal sphincter is then looped on a right angle and brought up into the incision. The internal sphincter is then cut under direct visualization. The 2 ends are allowed to fall back after being cut. A gap can then be palpated in the internal sphincter through the anal mucosa, as in the closed technique. The incision can be closed or left open to heal.

In the treatment of chronic anal fissures, the surgeon may choose to excise the fissure in conjunction with the lateral sphincterotomy. Take care to not include a piece of the internal sphincter with the excision. More simply, instead of excising the fissure along with the sphincterotomy and worrying whether it will heal, the surgeon can excise the hypertrophied papillae and the skin tag and leave the fissure to heal on its own. Sometimes, long-standing chronic fissures do not heal, even with an adequate sphincterotomy, and an advancement flap must be performed to cover the defect in the mucosa. This can be performed either at the time of the sphincterotomy if the surgeon does not think the fissure will heal or as a second procedure if the fissure does not heal.

Postoperative details: Sphincterotomy is performed either in an outpatient setting or as an office procedure, and patients return home the same day. Typically, minimal postoperative pain is associated with either the closed or open technique—usually no more than the fissure caused preoperatively. Pain from the fissure starts to abate almost immediately. The only postoperative restrictions are from the anesthetic, and many patients can return to normal activities the following day.

Follow-up care: Prescribe stool softeners and fiber supplementation after the surgery, and recommend fiber supplementation indefinitely to prevent future problems with constipation. Follow-up care usually consists of a single postoperative visit to ensure that the wound is healing appropriately and that the fissure has resolved.

 

Complications from surgery for anal fissure include infection, bleeding, fistula development, and—the most feared—incontinence.

Infection

Infection after sphincterotomy is rare and occurs as a small abscess in only 1-2% of patients, despite the inherent uncleanliness of the area. Treatment is drainage of the abscess. Antibiotics are necessary only if significant associated cellulitis occurs or if the patient is immunosuppressed.

Bleeding

Some ecchymosis may occur around the sphincterotomy site, but bleeding that requires therapy is extremely rare.

Fistula formation

Fewer than 1% of patients develop an anal fistula at the site of the sphincterotomy. This usually results from a breach of the mucosa at the time of the sphincterotomy. The fistula is often low and superficial and should be treated with fistulotomy.

Incontinence

The incidence and definition of incontinence vary dramatically from study to study and among the different procedures. Of patients undergoing the sphincter stretch, 12-27% report problems with continence after the procedure. This is most likely because this is an uncontrolled stretch of the anal sphincter and that both the internal and external sphincters are stretched.

Incontinence rates are much lower with a properly performed internal sphincterotomy than with sphincter stretch, and these rates depend on the definition of incontinence. In most patients, the minor soiling or incontinence to flatulence that may occur in the immediate postoperative period usually resolves without any long-term sequelae.

Recurrence or nonhealing of the fissure

The recurrence rate or nonhealing rate for anal fissures after surgical treatment is 1-6%. Several studies have found that up to 50% of subjects who did not heal had underlying and undiagnosed Crohn disease as the etiology for their fissure.

Approximately 1-6% of patients have a recurrence of their anal fissure after sphincterotomy. The recurrence rate is higher after a sphincter stretch. If a patient develops a recurrence after a sphincterotomy, it could be from recurrent disease or from an improperly or incompletely performed initial sphincterotomy. Medical management should be attempted again; but, if no relief is obtained, the surgeon must evaluate whether the original sphincterotomy was adequate. Evaluation can be performed by palpation during examination under anesthesia or by performing an endoanal ultrasound. If the sphincterotomy was incomplete, it can be completed on the initial side or redone on the opposite side. If the first sphincterotomy was complete, a second sphincterotomy can be completed on the opposite side.

Click to see larger picture

Anal Abscess and Fistula
An abscess is pus in a cavity  [neutrophils with dead tissues liquifactive necrosis] ,caused by infection usually from a bacteria. Acute infection of a small gland just inside the anus

Certain conditions, such as Crohn's disease (chronic inflammatory bowel disease FROM IMMUNE DISEASE, where the three layers of the gut are involved with a lymphocytes attacks), can increase the risk of abscess in and around the anal canal.

Patients with conditions that reduce the body's immunity, such as cancer or AIDS, are also more likely to develop anal abscesses no wonder if they cannot fight it they are weak to have any type infection.

An abscess causes redness, tenderness, swelling, and pain [and a painful lump where is start to get bigger , the pressure increase the pain, the big relief is when an incision is made into the abess releasing the pressure and the pus, the patient usually say a big ouuf of relief ]. The patient may complain of fever [any infection usually do have fever] , chills [leukitriene release] , and general weakness or fatigue.

Fistula

An anal fistula, almost always the result of a previous abscess, is a small tunnel connecting the anal gland from which the abscess arose to the skin of the buttocks outside the anus. iT IS THE SOUPAPE WAY TO ESCAPE , THE PRESSURE IS SO INTENSE THAT A WEAK SPOT IN THE ABSCESS  WITH THE INFLAMMATION GIVE THE FISTULA, BUT SOME TIMES ABESSCESS ARE NOT THE CAUSE BUT INFLAMMATION IS AS IN CASE OF CONTACT BETWEEN TWO INFLAMMED ORGAN [ about 50 percent of all abscess cases] .

 After an abscess has been drained, a tunnel may persist connecting the anal gland from which the abscess arose to the skin. If this occurs, persistent drainage from the outside opening may indicate the persistence of this tunnel. If the outside opening of the tunnel heals, recurrent abscess may develop.

  • Bacteria:
    1. Staphylococcus
    2. E.coli
    3. Streptococci
  • Proteus vulgaris
  • Pseudomonas aeruginosa
  • Bacteroides
  • Usually a mixture of above

Symptoms of both ailments include constant pain, sometimes accompanied by swelling, that is not necessarily related to bowel movements. Other symptoms include irritation of skin around the anus, drainage of pus (which often relieves the pain), fever, and feeling poorly in general.

  • Unable to sit comfortably
  • Difficulty or pain with passing stool
  • Redness or pain around anus
  • Abscess felt around anus or within anal canal
  • Peri-rectal swelling
  • Pain may be throbbing, sharp, or dull
  • Fever may be seen in severe case
  • Bleeding or discharge if abscess is drained or accidentally ruptures.
  • In elderly there maybe no fever only lower abdominal pain
  • If the abscess ruptures and leaves a fissure that opens into the anal canal, a fistula is formed.

RISK FACTORS [SOME OF THEM]

  • Cuts:
    1. From food such as egg shell and fish bone
    2. Swallowed objects, such as rings, coins, paperclips
  • Penetrating injuries:
    1. Constipation
    2. Enema
    3. Vibrators
    4. Anal sex
    5. Light bulbs
    6. Bottles
    7. Surgical injection of hemorrhoids
  • Diseases:
    1. Hemorrhoids (hang out from the anus opening)
    2. Inflammatory Bowel Disease
    3. Granulomatous diseases such as Sarcoidosis
    4. Weakened immune system (body's defenses) -- cancer (specially of blood), AIDS, etc.

Diagnosis
Diagnosis of an abscess is usually made on examination of the area. If it is near the anus, there is always pain, and often redness and swelling. The physician will look for an opening in the skin (a sign that a fistula has developed), and try to determine the depth and direction of the channel or tract of the fistula. However, signs of fistula and abscess may not be present on the skin's surface around the anus. In this case, the physician uses an instrument called an anoscope to see inside the anal canal and lower rectum.

Whenever the physician finds an abscess, and especially a fistula, further tests are needed to be sure Crohn's disease is not present. Blood tests, x-rays, and a colonoscopy (a lighted, flexible scope exam of the bowel or colon) are often required.

Treatment for Anal Abscess
An abscess must be surgically opened to promote drainage and relieve pressure as all abesscesses , do not treat an abscess with antibiotic it does not get through just open it. Under local anesthesia. However, patients with a large or deep abscess, or those who have other conditions, such as diabetes, may be admitted to the hospital for the procedure.

Antibiotics cannot take the place of draining an abscess. However, they are usually prescribed along with surgical drainage, especially if the patient has other serious diseases, such as diabetes or those associated with reduced immunity BUT USUALLY ANY ONE IS GIVEN ANTIBIOTICS  AFTER ANY SURGERY WE NEVER KNOW.

Treatment for Anal Fistula

Surgery is necessary to cure an anal fistula. Although fistula surgery is usually relatively straightforward, the potential for complication exists, and is preferably performed by a specialist in colon and rectal surgery. It may be performed at the same time as the abscess surgery, although fistulae often develop four to six weeks after an abscess is drained - sometimes even months or years later. Fistula surgery usually involves cutting a small portion of the anal sphincter muscle to open the tunnel, joining the external and internal opening and converting the tunnel into a groove that will then heal from within outward. However, if a large portion of the muscle is involved, your surgeon may choose to leave a suture (stitch) in the fistula first, followed by a second operation to cut the muscle at a later period. This operation needs to be done with care, as cutting too much muscle will lead to loss of control of bowel movement. Most of the time, fistula surgery can be performed on an outpatient basis - or with a short hospital stay.


Fistulotomy involves laying open or cutting along the length of the fistula (tunnel or tract) to the skins surface. This allows the wound to heal slowly from the base upwards.

Insertion of Seton Seton is a small flexible tube that is inserted into the fistula, this allows for drainage of debris from the abscess. Seton stops the skin from healing and pus accumulating within the abscess

Summary
Bleeding, pain, or drainage from the anus can occur with several illnesses, so a physician should always be consulted. Often the diagnosis is anal fissure, abscess, or fistula. These are problems that are usually easy to diagnose and correct. A variety of treatments, including surgery, are available to correct these conditions. Working together with the physician usually assures a good outcome.

 


 

 

 


 

 

 

Copyright ©2004 Sinoe Medical Association

Danil Hammoudi.MD