Bowel management can dramatically improve the quality of life of patients' suffering from constipation or fecal incontinence.
The most common error that we see when clinicians try to implement bowel management is to not utilize abdominal radiograph to evaluate the efficacy of their proposed treatment. This approach may leave patients with an inadequate laxative dosage or inadequate enema recipe. leading to increase patient and family frustration, recurrent bowel accidents, and the false impression that they do not respond to bowel management treatment.
In Europe, there has been publications about the use of hydrocolonic sonography for bowel management9–10. For daily assessment of stool load during a bowel management week, abdominal radiographs seem to be preferred in the USA, as they have lower cost, are fast, and less dependable on the child’s cooperation. They also provide easy visual assessment for both radiologists and clinicians.
Regarding the concern about radiation over abdominal radiographs, the average radiation for an abdominal radiograph at Children’s Hospital Colorado is 0.06 mSv (Fig. 14), which is similar to one day of background radiation11.
Over many years performing bowel management, we realized that there is no standardized reporting of abdominal radiographs during a bowel management week. Improving the radiograph reports may facilitate clinicians' success.
We understand that the problem can only be solved if both sides (clinician ordering the radiograph and radiologist interpreting the results) aim to understand each other’s needs. The clinician placing the order for the abdominal radiograph must state the diagnosis of the patient, as well as the treatment modality (enemas vs. laxatives) and the goal of the treatment being implemented during a bowel management week. The radiologist should be familiarized with the goals of the treatment and how his/her interpretation will guide the clinician on the treatment modification.
The goal of the bowel management week of patients with idiopathic constipation is to determine the amount of stimulant laxatives capable of emptying the colon, as radiologically demonstrated. Many of our patients were considered non-manageable because the constipation problem persisted after administering laxatives using the "recommended" dosage. In such cases, an abdominal radiograph allowed us to confirm that the colon was full of stool and that the patient required a much higher amount of laxative to be able to empty his/her colon. This repeated experience led us to conclude that the only objective way to determine whether the patient is receiving the right amount of laxative is with an abdominal radiograph.
In the process of finding the right amount of stimulant laxative or the right enema recipe, several abdominal radiographs are taken to guide us by trial and error to find the ideal management.
An informed radiologist needs to become involved in the process. A radiologist not educated about the plan may be distracted by reading other less important aspects of the abdominal radiograph that will have limited value for the bowel management purpose of the exam. The importance of correlation with the initial contrast enema and comparison with the previous day must be emphasized.
We propose a method of standardized interpretation as following:
Small bowel: (dilated or nondilated)
Each Colon Segment should be reported as: (air filled/fluid filled/small volume of stool(non-distended)/moderate volume of stool (formed stool filling approximately 50 % of the lumen) and large amount of stool (formed stool occupying the entire colon lumen) or markedly distended as seen with colon segment distended with formed stool.) A comment on if the volume has increased or decreased since the day prior would also be helpful.
Colonic segments should be broken into 5 categories including the following:
Right colon:
Transverse colon:
Left colon:
Rectosigmoid colon:
Rectal vault:
Abdomen: No free air. No pneumatosis.