(From the January 2015 Issue of PediatricsOnline)
Fluoroscopic defecography, a form of imaging that allows X-ray evaluation of a patient’s rectum at rest and while stooling, has been proposed as one of several imaging modalities to help evaluate the pathophysiology underlying defecation disorders in children that do not resolve with standard treatment. Although the procedure carries few risks, it is not routinely used in the diagnosis or therapeutic management of defecation disorders in children. But a study by clinician-scientists and collaborators at Nationwide Children’s Hospital reveals that fluoroscopic defecography may markedly improve management and outcomes for children with refractory defecation disorders.
The study, published in the journal Pediatric Radiology, reviewed all fluoroscopic defecography studies over a period of seven years involving patients at Nationwide Children’s Department of Gastroenterology, Hepatology and Nutrition who had normal anorectal motility studies but persistent defecation problems. Researchers examined the medical records of 18 patients to determine the impact of fluoroscopic defecography on directing diagnostic and therapeutic management.
“No other research we are aware of has evaluated the role of fluoroscopic defecography in changing or improving children’s treatment and outcomes,” says Hayat M. Mousa, MD, medical director of the Motility Program at Nationwide Children’s and senior author on the study. “We found that the imaging directly influenced therapeutic management for two-thirds of the participants, and in 75 percent of those children, the change was successful in managing the defecation problem.”
Children who do not respond to conventional treatment for defecation disorders require additional investigation, Dr. Mousa explains. Other imaging options include abdominal radiography, barium enema and MRI of the spine. Although these imaging modalities may be useful for detecting the underlying problem in certain cases, they cannot evaluate pelvic floor dysfunction, which fluoroscopic defecography allows.
Among study participants, fluoroscopic defecography was originally ordered to evaluate chronic defecation disorders in 56 percent of the patients, fecal incontinence in 22 percent and rectal prolapse in 22 percent. Pelvic floor dyssynergia was identified in 50 percent of cases, a structural abnormality was identified in 22 percent, and normal pelvic floor function was seen in 28 percent.
As a direct result of the fluoroscopy results, 22 percent of the participants (four children) were referred for anorectal biofeedback treatment, 22 percent for surgery, 11 percent for additional defecographic imaging, one for psychologic care and one for a change in medication. In the remaining one-third of participants, the imaging results did not change therapeutic management.
Although the technology is not the magic bullet to managing refractory defecation disorders, the researchers say, it is a valid approach for furthering diagnostic efforts and clinical management.
“Fluoroscopic defecography may often help reveal the underlying pathophysiology of what seems like an intractable defecation problem,” says Dr. Mousa, who also is a professor of Clinical Pediatrics at The Ohio State University College of Medicine. “By identifying specific treatment targets, such as malformations that can be addressed by surgery, fluoroscopy can meaningfully impact the clinical care and outcomes for patients.”
Mugie SM, Bates DG, Punati JB, Benninga MA, Di Lorenzo C, Mousa HM. The value of fluoroscopic defecography in the diagnostic and therapeutic management of defecation disorders in children. Pediatric Radiology. 2014 Sep 30. [Epub ahead of print]