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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. |