New Treatment for Rectal Impaction in Children: An Efficacy, Comfort, and Safety Trial of the Pulsed-Irrigation Enhanced-Evacuation Procedure

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To determine the efficacy, comfort, and safety of the pulsed-irrigation enhanced-evacuation (PIEE) procedure in children, we evaluated 27 procedures performed on 24 consecutive children, 16 boys and 8 girls, 4–15 years old (mean, 8.7), with chronic constipation, encopresis, and rectal impaction. Children with known heart, lung, and/or neurologic diseases were excluded. Temperature, pulse, respiratory rate, and blood pressure were obtained prior to, during, and immediately after the procedure. Abdominal radiographs were obtained before and after the procedure, and the degree of disimpaction was estimated by a single radiologist. Patients graded the discomfort of the procedure at the time of speculum insertion and every 15 min from 1 to 5: 1, painless; 2, mild discomfort; 3, moderate discomfort; 4, severe discomfort; 5, extremely painful. Serum sodium, potassium, chloride, and bicarbonate values were obtained before, immediately after, and 90 min after the procedure and compared by paired Student t analysis. A digital rectal examination confirmed rectal impaction prior to insertion of the speculum. One course of pulsed irrigations was performed, typically lasting 25–30 min. No significant changes in vital signs were found during or after the procedure. In 18 of 23 (78%) procedures, there was at least a 50% emptying of feces from the colon immediately after the procedure. Patients continued to empty their colon up to 12 h later; thus, the procedure effectively disimpacted all patients. In terms of comfort, patients graded the PIEE a 2.6 × 0.75 (range, 1–5). Speculum insertion was the most uncomfortable factor and received a 2.7. No child had any indication of water intoxication. Serum sodium levels (mean × SD) before the procedure were 139.4 × 1.95 mM. Immediate postprocedure levels fell to 136.8 × 2.21 m M, p < 0.05; 90 min later, they returned to 137.9 × 2.67 m M, p < 0.05. The largest change in serum sodium pre- and postprocedure was 7 m M (from 139 to 132), found in two patients. No other electrolyte changes were noted. In conclusion, the PIEE procedure successfully disimpacted all patients, either immediately or within hours of completion. Patients accepted the procedure well, and no clinically significant electrolyte changes were noted. This new method of rectal disimpaction appears to be safe, effective, and acceptable to children.

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