74 Scientific Solution to a Complex Problem: Physiology and MDT improve understanding and outcome in Chronic Constipation and Faecal Incontinence
Eleni Athanasakos, Sally Dalton, Susan McDowell, Tara Shea, Kate Blakeley, David Rawat, Stewart Cleeve
The Royal London Hospital, Barts Health NHS, London, United Kingdom

Abstract

Aim:  Assess the impact of an innovative children’s anorectal physiology service (CAPS) and weekly specialist multi-disciplinary team (MDT) focusing on improving outcomes in children with chronic constipation (CC) and faecal incontinence (FI).

Methods:  prospective data collected on all patients: age, sex, symptoms, co-morbidities, satisfaction. Bowel assessments (St Mark’s Incontinence Score [SMIC], Cleveland Constipation Score [CCS]). Diagnostics: awake high resolution anorectal manometry (AHRAM), endoanal ultrasound and transit marker studies (TMS). Psychosocial assessment undertaken. Referrals and management discussed in MDT. 

Results: 112 patients (112/137 (82%) assessed.  66 male (59%); median 9 years (17 months to 16 years).  99 (88%) patients had functional CC/FI, 10 (9%) Hirschsprungs disease, 11 (10%) anorectal malformation and 3 (3%) trauma.  SMIC  abnormal in 91 (81%) and CCS in 101 (90%). All patients had anorectal physiology: 94 (84%) awake and 18 (17%) under anaesthesia (combined with surgical procedure).  Health play specialist input 37 (33%) patients.  AHRAM abnormal 65 (58%): sphincter dysfunction 36 (32%) and altered sensation, tested in awake patients only (hyposensitive rectum 22% (20/91) [RH-]; 21% (19/91) hypersensitive rectum [RH+]).  TMS normal in 64 (57%), 17 (15%) slow transit and 27 (24%) rectal evacuatory disorder. 55% patients with normal TMS had abnormal physiology.   Risk of distress in 38% and poor quality of life in 55%, correlated with school difficulties (p = 0.04).  Abnormal SMIC scores correlated with poor quality of life (p=0.02).  Management was multimodal in 40% (toileting/medical modification, surgery, irrigation, biofeedback, interpshincteric botox, psychological and neuromodulation).  RH- patients predominantly treated with transanal irrigation and RH+ with toileting/medical modification, interpshincteric botox and psychological input. Patient/parent satisfaction with their management improved significantly (p= 0.05).

Conclusion:

  1. CAPS and specialised MDT improves satisfaction
  2. Symptoms do not predict physiology
  3. Improving outcomes in children with CC/FI is complex and benefits from regular MDT and AHARM

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