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T1153 Does the Use of Multichannel Intraluminal Impedance with pH (pH-MII) Change the Outcome of Patients with Suspected GERD?
T1154
Chronic abdominal pain and orthostatic intolerance (OI) co-exist in children and adolescents. Autonomic dysregulation leading to antroduodenal (AD) motility disorder and vascular symptoms could be the underlying pathogenic mechanism for these conditions. METHODS: Between 2004 and 2008, 81 subjects (74F:8M), 11-19 years old, underwent AD manometry (ADM) at our institution for complaints consistent with chronic abdominal pain. ADM was performed with a solid state, 6-channel Konigsberg® catheter placed endoscopically and analysis was performed using the MMS® software. The subjects also underwent a standard 70° upright tilt table test (TTT). Standard definitions were used: antral hypomotility (AH) - amplitude <30 mmHg or frequency <1/min; neurogenic intestinal dysmotilty (NID) - high amplitude clusters (HAC), retrograde propagation and other manometric abnormalities. RESULTS: A total of 73 subjects (90%) were positive for OI; either postural orthostatic tachycardia syndrome (POTS) (26%) or neurally mediated hypotension (NMH) (64%). Among those subjects with NMH, the ADM was abnormal in 98%; showing AH in 85%, NID in 46% and findings suggestive of pseudoobstruction in 11%. Of the subjects with POTS, ADM was abnormal in 86%, with AH in 58% and NID in 29%. Of the 8 subjects with normal TTT (10%), only 1 was abnormal, showing antral hypomotility (12%). Some subjects had more than one abnormal finding. CONCLUSIONS: Concomitant chronic abdominal pain and orthostatic intolerance indicates underlying antroduodenal motility disorders. Further studies would be helpful to confirm these findings, and to evaluate the efficacy of aggressive management of OI to improve chronic abdominal pain in these children.
T1152 Anorectal Manometry, Behavior Assessment and Colonic Transit Testing in Children with Combined Defecation and Voiding Symptoms Rosa Burgers, Olivia Liem, Hayat Mousa, Marc A. Benninga, Carlo Di Lorenzo Background: Cornerstones for evaluation of childhood constipation are symptom history and a thorough physical exam. Additional diagnostic tests such as anorectal manometry and colonic transit time measurement are commonly used. However, the child's emotional and behavioral status is not evaluated routinely. Aim: To investigate the possible correlation among anorectal manometry (AM), behavioral scores and colonic transit time in children with combined defecation and voiding disorders. Methods: We prospectively evaluated patients who were referred for combined defecation and voiding symptoms (day and night incontinence or infrequent voiding). All patients underwent AM, behavioral assessment and colonic transit time (CTT) measurement. During AM, we determined threshold for first rectal sensation and lowest volume required to elicit the rectoanal inhibitory reflex (RAIR). Parents were asked to fill out the Parenting Rating Scale about childhood psychopathology and behavior disorders (BASC-2). To measure CTT the patients swallowed a capsule with 10 markers during 6 consecutive days followed by an abdominal radiograph on day 7. A CTT longer than 62 hours was defined as abnormal. Spearman's rank correlation coefficients were calculated for the three different tests. Results: We enrolled 16 patients (10 girls, mean age 7.8 ± 1.8 yrs). Nine children showed a normal CTT (mean 22.7 ± 17, range 2.4-52.8 hours), 7 had a prolonged CTT (mean 80.7 ± 18, range 62.4-103.2 hours). Two children had T scores in the clinical range for externalizing problems and two others had at risk/ clinically significant scores for internalizing problems. Children with delayed CTT and rectal retention of markers required larger volumes to elicit RAIR (correlation coefficient 0.861, p= 0.01). Those with higher thresholds for sensation had lower T scores for externalizing problems (correlation coefficient -0.782, p= 0.04) and behavioral problems (correlation coefficient -0.873, p=0.01). In children with a normal CTT, higher T scores for externalizing problems and behavioral problems were present among those with a lower CTT (correlation coefficient -0.760, p= 0.02 and correlation coefficient -0. 765, p= 0.02 respectively). Conclusions: In children with both defecation and voiding disorders, behavioral problems seem to correlate with objective tests parameters. A significant correlation was found between AM, BASC and CTT. A comprehensive evaluation of the child emotional and behavioral components should be included in the work-up of the child presenting with symptoms of voiding dysfunction. T1153
T1155
Does the Use of Multichannel Intraluminal Impedance with pH (pH-MII) Change the Outcome of Patients with Suspected GERD? Rachel L. Rosen, Kristen Hart, Kate Donovan, Samuel Nurko
Constipation in Children Receiving Chemotherapy for Cancer: Prevalence, Risk Factors and Severity of the Problem Hale Season, Farzana Pashankar, Diana Beardsley, Joseph McNamara, Dinesh Pashankar
Background: pH-MII has been suggested as a new gold standard for the evaluation of reflux disease despite lack of evidence that its results change outcome beyond that of a standard pH probe. Methods: 50 consecutive patients that underwent MII-pH were included. After performing pH-MII studies, we sequentially gave clinicians results beginning with the pH results followed by the MII results. With each additional result, clinicians were asked how the results would change clinical management. Finally, clinicians were asked if they felt the MII overall changed their clinical management. Results: The primary reason for impedance testing was GI in 49%, respiratory in 19% and both GI and respiratory in 32%. pH probe results changed clinical management 40% of the time, MII results changed clinical management 22% of the time, and neither pH nor MII results changed management 38% of the time. The summary of reflux profiles affecting clinical management in each of the three categories is shown in the table below. The mean GI and pulmonary symptom indices for those patients where pH probe changed management were 26±40 and 36±35 respectively. The mean GI and pulmonary symptom indices for those patients where pH-MII changed management were 34±43 and 46±20 respectively. Conclusions: Impedance results changed management in less than one quarter of patients undergoing reflux testing. These changes were either due to elevated amounts of non-acid reflux or a positive symptom association or because the impedance results further reinforced the pH probe results. Neither the % time pH < 4, the number of reflux events (acid or non-acid) nor the symptom index individually predicted which tool was more clinically useful.
Background: Functional constipation is common in children with prevalence reported to be up to 22% in primary care pediatric clinics. Constipation occurs in children receiving chemotherapy for cancer but there are no data about prevalence, risk factors and severity of constipation in this group of children. Methods: We prospectively studied 38 children receiving chemotherapy for cancer. We administered questionnaire to children and parents and collected data on demographics, chemotherapy and medication details, use of laxatives, and bowel movement pattern during chemotherapy. We used five Rome III symptom criteria for diagnosis (excluding examination parameter). Severity of problem of constipation and impact on lifestyle during chemotherapy were assessed on 0-3 scale with 0 being no problem, 1 minor, 2 significant and 3 being a major problem. Results: A total of 38 children (23 male) with mean age of 10.7 years (range 2 to 19) participated in the study. Twenty three had leukemia and 15 had other malignancies outside the gastrointestinal tract. The mean duration of chemotherapy was 1.7 years. During chemotherapy history of painful or hard bowel movements was present in 31 children (82%), infrequent bowel movements in 18 (47% ), large stools in 15 (39%), retentive posturing in 9 (24%) and incontinence in 5 (13%). Constipation by Rome III criteria ( two of five criteria) was diagnosed in 21 children (55%) during chemotherapy. Laxatives such as colace, senna and polyethylene glycol were used as prophylaxis in 17 children and 11 developed constipation despite laxatives. Parents reported temporal relationship with onset of chemotherapy and constipation in 17 children. Of all commonly used chemotherapy and medications, vincristine use was more related to constipation (61%) compared to methotrexate or 6-mercaptopurine and 8 of 10 children on narcotics developed constipation. Twelve of 38 children and parents (32%)perceived constipation as major or significant problem and 7 children and their parents (18%) perceived constipation having major to significant impact on lifestyle during chemotherapy. Conclusions: Constipation was diagnosed in 55% of children receiving cancer chemotherapy. This prevalence is probably an underestimate as few children were taking prophylactic laxatives prior to the diagnosis and we could not apply all Rome III criteria. Chemotherapy with vincristine and use of opiates were related to the development of constipation. Constipation can be a significant problem with a negative impact on lifestyle during chemotherapy and needs to be treated aggressively.
A-511
AGA Abstracts
AGA Abstracts
Chronic Abdominal Pain and Orthostatic Intolerance Are Related to Underlying Antroduodenal Motility Disorders in Children and Adolescents Punit N. Jhaveri, Pooja B. Marria, John Desbiens, Peter C. Rowe, Anil Darbari
Chronic abdominal pain and orthostatic intolerance (OI) co-exist in children and adolescents. Autonomic dysregulation leading to antroduodenal (AD) motility disorder and vascular symptoms could be the underlying pathogenic mechanism for these conditions. METHODS: Between 2004 and 2008, 81 subjects (74F:8M), 11-19 years old, underwent AD manometry (ADM) at our institution for complaints consistent with chronic abdominal pain. ADM was performed with a solid state, 6-channel Konigsberg® catheter placed endoscopically and analysis was performed using the MMS® software. The subjects also underwent a standard 70° upright tilt table test (TTT). Standard definitions were used: antral hypomotility (AH) - amplitude <30 mmHg or frequency <1/min; neurogenic intestinal dysmotilty (NID) - high amplitude clusters (HAC), retrograde propagation and other manometric abnormalities. RESULTS: A total of 73 subjects (90%) were positive for OI; either postural orthostatic tachycardia syndrome (POTS) (26%) or neurally mediated hypotension (NMH) (64%). Among those subjects with NMH, the ADM was abnormal in 98%; showing AH in 85%, NID in 46% and findings suggestive of pseudoobstruction in 11%. Of the subjects with POTS, ADM was abnormal in 86%, with AH in 58% and NID in 29%. Of the 8 subjects with normal TTT (10%), only 1 was abnormal, showing antral hypomotility (12%). Some subjects had more than one abnormal finding. CONCLUSIONS: Concomitant chronic abdominal pain and orthostatic intolerance indicates underlying antroduodenal motility disorders. Further studies would be helpful to confirm these findings, and to evaluate the efficacy of aggressive management of OI to improve chronic abdominal pain in these children.
T1152 Anorectal Manometry, Behavior Assessment and Colonic Transit Testing in Children with Combined Defecation and Voiding Symptoms Rosa Burgers, Olivia Liem, Hayat Mousa, Marc A. Benninga, Carlo Di Lorenzo Background: Cornerstones for evaluation of childhood constipation are symptom history and a thorough physical exam. Additional diagnostic tests such as anorectal manometry and colonic transit time measurement are commonly used. However, the child's emotional and behavioral status is not evaluated routinely. Aim: To investigate the possible correlation among anorectal manometry (AM), behavioral scores and colonic transit time in children with combined defecation and voiding disorders. Methods: We prospectively evaluated patients who were referred for combined defecation and voiding symptoms (day and night incontinence or infrequent voiding). All patients underwent AM, behavioral assessment and colonic transit time (CTT) measurement. During AM, we determined threshold for first rectal sensation and lowest volume required to elicit the rectoanal inhibitory reflex (RAIR). Parents were asked to fill out the Parenting Rating Scale about childhood psychopathology and behavior disorders (BASC-2). To measure CTT the patients swallowed a capsule with 10 markers during 6 consecutive days followed by an abdominal radiograph on day 7. A CTT longer than 62 hours was defined as abnormal. Spearman's rank correlation coefficients were calculated for the three different tests. Results: We enrolled 16 patients (10 girls, mean age 7.8 ± 1.8 yrs). Nine children showed a normal CTT (mean 22.7 ± 17, range 2.4-52.8 hours), 7 had a prolonged CTT (mean 80.7 ± 18, range 62.4-103.2 hours). Two children had T scores in the clinical range for externalizing problems and two others had at risk/ clinically significant scores for internalizing problems. Children with delayed CTT and rectal retention of markers required larger volumes to elicit RAIR (correlation coefficient 0.861, p= 0.01). Those with higher thresholds for sensation had lower T scores for externalizing problems (correlation coefficient -0.782, p= 0.04) and behavioral problems (correlation coefficient -0.873, p=0.01). In children with a normal CTT, higher T scores for externalizing problems and behavioral problems were present among those with a lower CTT (correlation coefficient -0.760, p= 0.02 and correlation coefficient -0. 765, p= 0.02 respectively). Conclusions: In children with both defecation and voiding disorders, behavioral problems seem to correlate with objective tests parameters. A significant correlation was found between AM, BASC and CTT. A comprehensive evaluation of the child emotional and behavioral components should be included in the work-up of the child presenting with symptoms of voiding dysfunction. T1153
T1155
Does the Use of Multichannel Intraluminal Impedance with pH (pH-MII) Change the Outcome of Patients with Suspected GERD? Rachel L. Rosen, Kristen Hart, Kate Donovan, Samuel Nurko
Constipation in Children Receiving Chemotherapy for Cancer: Prevalence, Risk Factors and Severity of the Problem Hale Season, Farzana Pashankar, Diana Beardsley, Joseph McNamara, Dinesh Pashankar
Background: pH-MII has been suggested as a new gold standard for the evaluation of reflux disease despite lack of evidence that its results change outcome beyond that of a standard pH probe. Methods: 50 consecutive patients that underwent MII-pH were included. After performing pH-MII studies, we sequentially gave clinicians results beginning with the pH results followed by the MII results. With each additional result, clinicians were asked how the results would change clinical management. Finally, clinicians were asked if they felt the MII overall changed their clinical management. Results: The primary reason for impedance testing was GI in 49%, respiratory in 19% and both GI and respiratory in 32%. pH probe results changed clinical management 40% of the time, MII results changed clinical management 22% of the time, and neither pH nor MII results changed management 38% of the time. The summary of reflux profiles affecting clinical management in each of the three categories is shown in the table below. The mean GI and pulmonary symptom indices for those patients where pH probe changed management were 26±40 and 36±35 respectively. The mean GI and pulmonary symptom indices for those patients where pH-MII changed management were 34±43 and 46±20 respectively. Conclusions: Impedance results changed management in less than one quarter of patients undergoing reflux testing. These changes were either due to elevated amounts of non-acid reflux or a positive symptom association or because the impedance results further reinforced the pH probe results. Neither the % time pH < 4, the number of reflux events (acid or non-acid) nor the symptom index individually predicted which tool was more clinically useful.
Background: Functional constipation is common in children with prevalence reported to be up to 22% in primary care pediatric clinics. Constipation occurs in children receiving chemotherapy for cancer but there are no data about prevalence, risk factors and severity of constipation in this group of children. Methods: We prospectively studied 38 children receiving chemotherapy for cancer. We administered questionnaire to children and parents and collected data on demographics, chemotherapy and medication details, use of laxatives, and bowel movement pattern during chemotherapy. We used five Rome III symptom criteria for diagnosis (excluding examination parameter). Severity of problem of constipation and impact on lifestyle during chemotherapy were assessed on 0-3 scale with 0 being no problem, 1 minor, 2 significant and 3 being a major problem. Results: A total of 38 children (23 male) with mean age of 10.7 years (range 2 to 19) participated in the study. Twenty three had leukemia and 15 had other malignancies outside the gastrointestinal tract. The mean duration of chemotherapy was 1.7 years. During chemotherapy history of painful or hard bowel movements was present in 31 children (82%), infrequent bowel movements in 18 (47% ), large stools in 15 (39%), retentive posturing in 9 (24%) and incontinence in 5 (13%). Constipation by Rome III criteria ( two of five criteria) was diagnosed in 21 children (55%) during chemotherapy. Laxatives such as colace, senna and polyethylene glycol were used as prophylaxis in 17 children and 11 developed constipation despite laxatives. Parents reported temporal relationship with onset of chemotherapy and constipation in 17 children. Of all commonly used chemotherapy and medications, vincristine use was more related to constipation (61%) compared to methotrexate or 6-mercaptopurine and 8 of 10 children on narcotics developed constipation. Twelve of 38 children and parents (32%)perceived constipation as major or significant problem and 7 children and their parents (18%) perceived constipation having major to significant impact on lifestyle during chemotherapy. Conclusions: Constipation was diagnosed in 55% of children receiving cancer chemotherapy. This prevalence is probably an underestimate as few children were taking prophylactic laxatives prior to the diagnosis and we could not apply all Rome III criteria. Chemotherapy with vincristine and use of opiates were related to the development of constipation. Constipation can be a significant problem with a negative impact on lifestyle during chemotherapy and needs to be treated aggressively.
A-511
AGA Abstracts
AGA Abstracts
Chronic Abdominal Pain and Orthostatic Intolerance Are Related to Underlying Antroduodenal Motility Disorders in Children and Adolescents Punit N. Jhaveri, Pooja B. Marria, John Desbiens, Peter C. Rowe, Anil Darbari