الفهرس 
EMBRYOLOGY, ANATOMY, AND PHYSIOLOGY OF RECTUM AND ANAL CANAL
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Abstract
This prospective follow up clinical study was carried out
to evaluate children with FI presented to the Pediatric
Outpatient Clinic, Children Hospital, Ain Shams University as
well as referral from primary or secondary health centers.
They were followed up in the Pediatric Gastroenterology Unit
and Pediatric Psychiatry Clinic.
The study included
80 children presented with isolated
secondary fecal incontinence. Twenty children with chronic
functional constipation without encopresis were included in
the study to be compared with those with retentive encopresis
regarding anorectal manometry parameters. So, the study
included a total of 100 patients, 82 males and 18 females with
an age ranging between 4.5 and 13 years old and a mean age
of 8.5 ± 2.2 years.
Encopretic children were followed up in Pediatric
Gastroenterology Clinic and Pediatric Psychiatry Clinic every
2 weeks for one year.
All encopretic cases were subjected to thorough history
taking, with analysis of symptoms of constipation, and
encopresis. General, abdominal, and per/rectum examination
were performed for all cases. All cases underwent base line
investigations including CBC, blood chemistry panel (Ca, Mg,Na, K, Liver functions tests, and renal functions tests).
Complete stool and urine analysis were performed for
encopretic cases.
Various imaging procedures were done, plain x-ray of
the abdomen, abdominal sonography, and barium enema for
exclusion of surgical causes, and for presence of features as
dilated colon.
Anorectal manometry was performed at presentation for
encopretic and constipated cases and after management for
encopretic children only.
Anxiety, depression, and HRQOL scores were
performed only for encopretic children at presentation and
after management.
Family education, behavioral management (toilet
training), and biofeedback started for all patients. For retentive
encopretic cases; treatment of constipation (regular evacuation
enema, and maintenance laxative). For non-retentive cases;
family education; and psychosocial support were the
cornerstone of management.
Statistical analysis of data of encopretic cases revealed
that the retentive type of encopresis (RFI) is the most common
type in our series (68 cases; 85%). Their ages, age at onset of
encopresis, duration of encopresis, duration of continence prior
to encopresis and frequency of encopresis per week ranged from
4.5 to
13.0 (mean =
8.4 ±
2.2) years,
4.0 to 12.0 years
(mean =
5.7 ±
1
.9) years,
6.0 to
72.0 months (mean =
32.1 ±
16.7) months,
6.0 to 96.0 months (mean
= 31.4 ± 21.2)
months, and
2 to 20 (mean =
7.6 ±
4.7) respectively. There
were no significant difference between retentive and nonretentive
cases regarding age at onset, and duration of
encopresis.
Regarding gender difference, the result of the present
series showed male sex predominance with (male: female ratio
= 5.7:1) among encopretic children with no significance
difference between retentive (male: female ratio = 7.5:1) and
nonretentive
type (male: female ratio = 2:1).
The most frequent order of birth
in our series was the 1st
order of birth (45.0%) followed by the 2nd order of birth
(27.5%) and 3rd
order of birth (15.0%). The most frequent
family size in our series was 4 persons (37.5%) followed by 5
persons (27.5%) and 6 persons (22.5%).
Forty six (5
7.5%)
encopretic children in our series showed no history of parental
consanguinity. Fifty four cases; ٦٧.٥% in our series live in
urban areas. There were no significant differences between
retentive and non-retentive types regarding previous
sociodemographic data.
Family troubles were found among 6 cases (7.5%)
including divorce (4 cases; 5%) and home changes (2 cases; 2.5%) with significantly higher frequency among NRFI (50%)
compared to RFI (0%).
Abdominal pain was the most frequent gastrointestinal
sy
mptom in the present series (90.0% of all encopretic
children) with significantly higher frequency among RFI
(97.0%) compared to NRFI (50%). The results of the present
study showed significantly lower frequencies of pain during
defecation, fear of defecation, stool withholding, difficult
defecation, abdominal distention, abdominal fecal mass, and
palpable colon among children with non-retentive encopresis
compared to those with retentive encopresis.
Regarding anthropometric measurements; 2.5% of
included c
hildren had underweight (weight below 5th centile
for age) and 15% had short stature (height below 5th centile for
age) with no significant difference between retentive and nonretentive
cases.
As regards barium enema findings, there was significant
difference between RFI and NRFI as all cases with nonretentive
encopresis showed normal intestinal loops and all
cases of retentive type showed dilated loops.
As regards anorectal manometry findings in our series;
the mean resting pressure of the internal anal sphincter among
encopretic children was 49.5 ± 18
.5 mmHg with significantly
lower value among children with RFI (47.1 ± 18.9 mmHg)compared to NRFI (63.3 ± 7.8 mmHg). No significant
difference was found between children with RFI and children
with chronic functional constipation without encopresis
regarding resting pressure of internal anal sphincter. Low
resting pressure of the internal anal sphincter was found
among 40% of encopretic children with significantly higher
frequency among children with RFI (47
.1%) compared to
children with NRFI (0%). Low resting pressure of the internal
anal sphincter was found among 50% of children with chronic
functional constipation without encopresis. High resting
pressure of the internal anal sphincter was found among 10%
of encopretic children with no significant difference between
RFI (8.8%) and NRFI (16.7%). High resting pressure of the
internal anal sphincter was found among 20% of children with
chronic functional constipation without encopresis. Normal
resting pressure of internal anal sphincter at presentation was
found among 50% of encopretic children and 30% of children
with chronic functional constipation without encopresis. After
treatment, the frequency of normal resting pressure increased
to 65% and frequency of low resting pressure decreased to
25%, while the frequency of high resting pressure remained
the same. The improvement of resting pressure of internal anal
sphincter was significantly higher among children with good
outcome (72% normal, 14% low pressure a
nd 14% high pressure) compared to children with poor outcome (53.3%
normal, 43.3% low,
and 3.3% high pressure).
Regarding maximum squeeze pressure of the external
anal sphincter; the mean maximum squeeze pressure at
presentation was 88.3 ± 24.7 mmHg, with significantly lower
mean value among children with RFI (86.0 ± 25.4 mmHg)
compared to children with NRFI (101.7 ± 15.3 mmHg). Fifty
percent of encopretic children had low maximum squeeze
pressure with no significant difference between RFI (
52.9%)
and NRFI
(33.3%). After treatment, the frequency of low
maximum squeeze pressure decreased to
30% of children with
significantly higher frequency among children with poor
outcome (
46.7%) compared to children with good outcome
(
20%).
Regarding the first sensation at presentation, the mean
first sensation volume was 75.7 ± 53.9 mL, with significantly
higher mean value among children with RFI (81.2 ± 56.6 mL)
compared to children with NRFI (44.2 ± 13.2 mL).The
frequency of high first sensation volume was found in 85% of
all encopretic children with no significant difference between
children with RFI (82.4%) and children with NRFI (100%).
Children with chronic functional constipation without
encopresis had significantly higher mean first sensation
volume (
204.9 ± 46.5 mL) compared to those with RFI.Impaired rectal sensation with increased first sensation volume
was found among 100% of children with constipation and
8
2.4% of retentive encopretic children.
After treatment, 75%
of encopretic children still have high first sensation volume,
with significantly higher frequency among children with poor
outcome (100%) compared to children with good outcome
(60%).
Regarding desire for defecation volume (urge), the mean
urge volume at presentation was 124.9 ± 53.0 mL with
signi
ficantly higher mean urge volume among RFI (134.0 ±
52.2 mL) compared to NRFI (73.1 ± 11.7 mL). More than half
(52.5%) of encopretic children had high urge volume status
with significant higher frequency among children with RFI
(61.8%) compared to childre
n with NRFI (0%). Fifteen
percent of encopretic children had low urge volume with
significantly higher frequency among children with NRFI
(33.3%) compared to children with RFI (11.8%). Seventy five
percent of constipated children had high urge volume with no
significant difference compared to RFI (61.8%).
Regarding maximum tolerable volume; the mean
maximum tolerable volume at presentation ranged from 72 to
270 ml (mean = 170.0 ± 58.2) with significantly lower mean
maximum tolerable volume among non-retent
ive (111.4±24.1)
versus retentive (180.4 ± 56.3). Eighty seven percent of encopretic children had low maximum tolerable volume status
with no significant difference between nonretentive
(83.3%)
compared to retentive (88.2%) cases. After treatment; the
frequency of low maximum tolerable volume status among
nonretentive
cases was increased to 100.0%. None of our
children had high maximum tolerable volume status before
and after treatment. There was no significant difference
between retentive encopretic compared to constipated cases
without encopresis regarding maximum tolerable volume.
Concerning psychiatric assessment in our series; the
mean anxiety score at presentation ranged from 10 to 45 (mean
= 28.1 ± 7.3) with significantly higher mean score among
chi
ldren with NRFI (35.8 ± 7.1) compared to children with
RFI (26.8 ± 6.5). One third of encopretic children had severe
degree of anxiety with significantly higher frequency among
children with NRFI (66.7%) compared to children with RFI
(26.5%) cases. After treatment, the mean anxiety score
improved and ranged from
6 to
41 (mean =
19.6 ±
6.8) with
significantly still higher mean score among children with
NRFI (
24.0 ±
8.9) compared to children with RFI (
18.9
± 6.
1).
The frequency of severe degree of anxiety was decreased from
66.7%
to 16.7% in non-retentive
and from 26.5%
to 2.
9% in
retentive cases with significant difference.The mean depression score at presentation ranged from
14 to 24 (mean = 18.9 ± 2.4) with significantly higher mean
score among non-retenti
ve (21.1 ± 2.9) versus retentive (18.6
± 2.2). Thirty percent of encopretic children had severe degree
of depression with significantly higher frequency among
children with NRFI (83.3%) compared to children with RFI
(20.6%). After treatment, the mean depression score improved
and ranged from
6 to
24 (mean =
12.1 ±
4.2) with significantly
still higher mean score among children with NRFI (
16.3 ±
5.7)
compared to children with RFI (
11.3 ±
3.5). The frequency of
severe degree of depression was decreased
from 83
.3% to
16.7% in nonretentive
cases and from 20.6% to
0.0% in
retentive cases with significant difference.
Concerning HRQOL; the mean pediatric HRQOL score
at presentation ranged from 56 to 78 (mean = 66.3 ± 4.7) with
significantly lower mean score among children with NRFI
(61.7 ± 4.4)
compared to children with RFI (67.2 ± 4.4). After
treatment, the pediatric HRQOL score in our series improved
and ranged from 65 to 80 (mean = 72.1 ± 4.0) with
significantly lower mean score among children with NRFI
(68.3 ±
2.6) compared with those with RFI (72.8 ± 3.9).
The mean parent HRQOL score at presentation was 63.3
± 4.8 with significantly lower mean score among parents of
children with NRFI (59.0 ± 5.4) compared to those of children with RFI (64.1 ± 4.3). After treatment, the mean parent
HRQOL score improved (71.7 ± 3.7), but still significantly
lower for NRFI (69.3 ± 4.4) compared to those of RFI (72.2 ±
3.5).
Concerning the outcome of encopretic children after
management; 50 cases (62.5%) of the treated patients had
recovery while 30 cases (37.5%) had failure of treatment.
There was significant higher frequency of NRFI among
children with poor outcome (26.7%) compared to those with
good outcome (8.0%). The mean duration of encopresis was
significantly longer among ch
ildren with poor outcome (37.2 ±
18.1 months) compared to children with good outcome (29.0 ±
15.3 months). This indicates that delay in diagnosis and start
of therapy is related to poor outcome. Children with poor
outcome had significantly higher frequency of male sex
(26.7%) compared to those with good outcome (8.0%). No
differences between children with good outcome and poor
outcome as regards age, age at onset of encopresis, duration of
continence prior to encopresis, frequency of encopresis per
week, order of birth, family size, family troubles.