Evaluation of Splanchnic Blood Flow Using Doppler Ultrasound Before and After Constipation Treatment in Patients with Bladder and Bowel Dysfunction

doi:10.21203/rs.3.rs-4844651/v1

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Evaluation of Splanchnic Blood Flow Using Doppler Ultrasound Before and After Constipation Treatment in Patients with Bladder and Bowel Dysfunction

https://doi.org/10.21203/rs.3.rs-4844651/v1

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Purpose: To evaluate the correlation between blood flow dynamics using conventional and Doppler ultrasound (US), and to assess the rectosigmoid ratio ultrasonographically in children with suspected bladder and bowel dysfunction (BBD).

Methods: This prospective study was conducted between January 2023 and January 2024 involving 62 children aged 5–18 years. Ultrasound were used to measure peak systolic velocity (PSV), pulsatility index (PI), resistive index (RI) of arteries, and the rectosigmoid ratio (R/S). Behavioral therapy and osmotic laxative treatment were administered for 3 months, followed by reassessment.

Results: Before treatment, the study group had a mean rectal diameter of 18 ± 15.5 mm, which increased to 23.5 ± 14.25 mm post-treatment (p = 0.008). The mean sigmoid colon diameter was 18.5 ± 10 mm before treatment and 18 ± 5 mm after treatment (p = 0.004). The rectosigmoid ratio (R/S) increased from 0.97 ± 0.76 to 1.27 ± 0.65 post-treatment (p = 0.036). No significant differences were found in the aortic, CA, and SMA flow velocities, PI, and RI between the groups or pre- and post-treatment within the study group. However, patients with an R/S index ≥1 had lower celiac PSV values compared to those with an R/S index <1 (p = 0.009).

Conclusion: Doppler ultrasound evaluation of intestinal blood flow did not show significant clinical benefits, it may offer insights for future research. Noninvasive measurement of the rectosigmoid index is useful in diagnosing and planning treatment for constipation, especially in cases with diffuse motility problems rather than fecal impaction.

bladder and bowel dysfunction

diagnosis

Doppler ultrasound (US)

intestinal blood flow

rectosigmoid ratio

Relationship between bladder and bowel dysfunction in children has been studied since the 1960s. The prevalence of constipation in children with lower urinary tract symptoms (LUTS) is reported to be 35.2%. [1] Furthermore, the incidence of LUTS is 6.8 times higher in children with constipation. LUTS can present with symptoms such as incontinence, frequent urination, sudden need to urinate, difficulty initiating urination, straining to urinate, weak urine flow, intermittent urination, and dysuria. [2] Thus, complications such as urinary tract infections, vesicoureteral reflux (VUR), and/or renal function loss may occur. [2] An early diagnosis and treatment of constipation in these patients can help prevent complications by preventing chronic progression of LUTS symptoms. In bladder and bowel dysfunction, plain abdominal radiograph and/or ultrasonographic transverse diameter of the rectum is used for diagnosis along with anamnesis and physical examination. [3] However, although the cause of LUTS in patients with constipation is often fecal impaction in the rectum, some patients may have a diffuse fecal load without impaction. [4]

In previous studies, Doppler ultrasonography revealed changes in the blood flow of the vessels supplying the intestines in the presence of bowel obstruction and strangulation [5]. However, there are no studies indicating whether changes in blood flow occur in patients with diffuse fecal load in all colonic segments. This study aims to evaluate the correlation between the flow dynamics in the aorta, celiac artery (CA), and superior mesenteric artery (SMA) as detected by conventional and Doppler ultrasound (US), and the rectosigmoid ratio was calculated ultrasonographically in patients with suspected bladder and bowel dysfunction (BBD). Thus, this study aimed to assess the usefulness of combining conventional and Doppler ultrasound as a noninvasive method for determining the severity of constipation, providing appropriate treatment, and evaluating the response to treatment.

The study was prospectively conducted between January 2023 and January 2024 at a tertiary referral university hospital. Approval was obtained from the ethics committee of the hospital (2023/0201).

Patients with LUTS were evaluated according to the Rome IV criteria. The Rome IV criteria for FC consist of the following six criteria evaluated over the preceding month: the presence of less than two bowel movements per week, at least one episode of fecal incontinence per week, holding maneuvers, pain or straining at defecation, a fecal mass in the rectum, and feces that obstruct the toilet bowl. Patients had least two positive Rome criteria were considered constipated. Patients aged 5–18 years who met the criteria and had diffuse fecal load in all colonic segments on abdominal X-rays were included in the study. [6] LUTS symptoms included nocturnal and/or daytime urinary incontinence, frequent urination, urgent need to urinate, difficulty initiating urination, straining to urinate, weak urine flow, reduced urine output, and dysuria. Patients with a Blethyn score of ≥2 grades on abdominal X-rays were included. In grade 2, feces is present in all segments of the colon. In grade 3 shows continous feces in all segments with a dilated colon and rectal impaction. [7] The control group comprised healthy children of similar age and gender who presented to the pediatric surgery clinics for routine follow-up.

Patients with chronic diseases; endocrine, neurological, and metabolic disorders; anorectal malformations; Hirschsprung disease; and those who had undergone abdominal surgery were excluded from the study.

Imaging protocol: Abdominal Doppler ultrasound measurements were performed by the same radiologist with a 3.5 MHz convex array transducer using Aplio 500 (Toshiba, Otawara, Japan) in the supine position. After the initial evaluation of the patients, abdominal Doppler ultrasound was performed following a 12-hour period of fasting before starting constipation treatment. In Doppler ultrasound, the abdominal aorta and its branches, such as the SMA and CA, were examined in both transverse and longitudinal scans. Peak systolic velocity (PSV) (cm/sec), pulsatility index (PI), and resistive index (RI) of all arteries were evaluated on Doppler ultrasound imaging. Vascular resistance was defined by the RI and the PI. For arterial vessels, RI and PI were automatically calculated with the software included in the ultrasound system.

Additionally, the transverse diameter of the rectum (R) and sigmoid colon (S) was measured ultrasonographically, and the rectosigmoid index (R/S) was calculated and analyzed. An R/S ratio of 1 or greater was considered normal. Patients were also grouped as R/S <1 and >1.

After the initial assessment, patients were advised to follow a dietary regimen, ensure adequate water intake, and adopt appropriate sitting positions on the toilet as part of behavioral therapy. Additionally, after fecal impaction was relieved, all patients received osmotic laxative therapy for 3 months. In the outpatient clinic, after reassessment using the Rome IV criteria, patients were evaluated again through anamnesis and physical examination, and then re-evaluated with conventional and Doppler ultrasound.

STATISTICAL ANALYSIS

All statistical analyses were performed using the IBM SPSS Statistics Standard Concurrent User V 29 package program (IBM Corp., Armonk, New York, USA). Descriptive statistics were presented as frequency and percentage values for categorical variables, and as mean ± standard deviation, median, and interquartile range values for numerical variables. Shapiro–Wilk’s test was used to assess the normality distribution of the variables. Levene’s test was used to assess the variance homogeneity. A two-sided Student’s t-test or a two-sided Mann–Whitney U test was used to compare the differences between groups for continuous variables. Furthermore, Wilcoxon test was used for pre- and post-treatment comparisons for BBD patients. A two-sided chi-square test with continuity correction was used to compare differences between groups for categorical variables. A p-value of <0.05 was considered statistically significant in all analyses.

Overall, 62 patients were evaluated; 32 patients with LUTS in the study group and 30 patients in the control group. The study group included 23 girls (71.9%) and 9 boys (28.1%), whereas the control group comprised 15 girls (50%) and 15 boys (50%).

Gender distributions between the groups were statistically similar (p = 0.132). The mean age was 8.7 ± 2.9 years in the study group and 9.9 ± 3.3 years in the control group. There was no statistically significant age difference between the groups (p = 0.132).

The patients’ symptoms are presented in Table 1. The mean duration of constipation in the study group was 25 ± 15 months. All patients had diffuse fecal load on direct abdominal radiographs. (Figure 1-2)

On USG, mean rectal diameter was 18 ± 15.5 mm in the study group before treatment and 27.5 ± 18.25 mm in the control group (p = 0.008) (Figure 3-4). After treatment, mean rectal diameter in the study group was 23.5 ± 14.25 mm. Posttreatment values were similar to the control group (p = 0.313)

On USG, mean sigmoid colon diameter was 18.5 ± 10 mm in the study group before treatment and 23 ± 11.5 mm in the control group (p = 0.043).After treatment, mean sigmoid colon diameter was 18 ± 5 mm in the study group (p = 0.004)

In the study group, 20 patients had an R/S ratio of <1 (62.5%), and 12 patients had an R/S ratio of ≥1 (37.5%). Before treatment, mean R/S ratio was 0.97 ± 0.76 in the study group and 1.27 ± 0.44 in the control group (p = 0.101). After treatment, mean R/S ratio in the study group was 1.27 ± 0.65. According to intragroup comparison, the post-treatment R/S values of the study group were statistically higher compared to the pre-treatment values (p = 0.036).

No statistically significant differences were found between the groups or between pre- and post-treatment values in the study group for the aortic, CA, and SMA flow velocities, RI, and PI. The flow velocities, PI and RI values for the aorta, CA, and SMA in the study and control groups are presented in Table 2.

In the patient group, when examining the aortic PSV, celiac PSV, and SMA PSV values before and after treatment in the study group based on the R/S index, it was observed that the celiac PSV values in patients with an R/S index ≥1 cm were statistically lower compared to those with an R/S index <1 cm (p = 0.009). No statistically significant differences were observed between the other values (Table 3).

In patients presenting with LUTS, no statistically significant differences were found in the flow dynamics of intestinal vessels on Doppler ultrasound before and after treatment. However, the rectosigmoid ratio was <1 in the study group before treatment and >1 after treatment. Moreover, the celiac PSV value was found to be lower in patients with a rectosigmoid ratio of <1.

The present study was initiated on the assumption that there might be dynamic changes in intestinal blood flow in patients with LUTS and fecal load in all colonic segments as seen on abdominal X-rays. These values were first evaluated in normal patients and then assessed within the study group after treatment. Although differences in mesenteric blood flow were observed between the study group before and after treatment and the control group, these differences were not statistically significant.

The prevalence of BBD in school-aged children is reportedly 9.1%–21.8%. In the present study, similar to what has been reported in the literature, BBD was more commonly observed in girls. [2]

Diagnosis of BBD is typically based on the patient’s anamnesis and physical examination. [8] Most children do not require any diagnostic tests. However, understanding the underlying pathophysiological mechanisms or possible organic etiology, evaluating the fecal load in the rectum and bowel due to constipation, and ultimately tailoring effective treatment requires additional diagnostic tests. [9,10,11]

Radiological evaluation of constipation can be performed by various methods. Abdominal X-rays can be used to assess fecal accumulation in the colon and rectum; however, this technique cannot reliably diagnose rectal dilation (megarectum) due to potential inaccuracies in measurements. Moreover, in the present study, despite the presence of diffuse fecal load in all colonic segments on plain X-rays, conventional and Doppler ultrasound evaluation revealed that the transverse diameter of the rectum in the study group was smaller compared to the control group. Many previous studies have shown that fecal impaction is associated with an increased transverse diameter of the rectum in patients with constipation and in those with BBD. [11] This suggested that the problem in the patients included in the present study was not fecal impaction but rather a motility issue affecting all intestinal segments, similar to slow-transit constipation. [12,13]

Thus, unlike previous studies, we calculated the rectosigmoid ratio by measuring the transverse diameters of the rectum and sigmoid colon using ultrasound in our study patients. [11] Consequently, it was found that the rectosigmoid index was <1 before treatment, but it showed significant improvement and increased to ≥1 after treatment. Therefore, we concluded that measuring the rectosigmoid index through noninvasive ultrasound is also helpful in these patients.

Changes in the resistance of the mesenteric arterioles cause fluctuations in intestinal blood flow. [14] Typically, literature reports the aortic PSV in children as 126.9 ± 14.7. [15] In our series, these values in the study group were similar to those in the control group but were higher than normal. The CA PSV has been found to be 158.2 ± 38.7 cm/s in normal patients. Previous studies have reported the SMA PSV as 140 cm/s and the RI as 0.89. [16] The findings from the present study were consistent with the literature.

In Hirschsprung’s disease, a previous study demonstrated that after surgical treatment, there is a decrease in the flow rates in the CA, SMA, and inferior mesenteric artery, and an increase in the RI. [17] In the present study, after constipation treatment, increased flow rates were observed in the intestinal bed, except for the CA, along with reduced resistance and vessel pulsatility. Repeating the study with a larger sample size, those undergoing longer-term constipation treatment, or individuals with treatment-resistant constipation could help validate this hypothesis. The results of this study indicate that measuring the flow velocity in various parts of the blood vessels supplying the intestines could help in the selection and planning of appropriate treatment options and in patient follow-up. [18] Additionally, it would have been possible to obtain more evidence-based results if a colon motility study could have been conducted in this patient group.

It is crucial to assess constipation in patients presenting with LUTS. However, in these patients, symptoms and radiological imaging are not always correlated. Evaluating plain abdominal X-rays for fecal load in these patients indicates the need for constipation treatment. Additionally, the transverse diameter of the rectum may still appear normal. Therefore, in patients where the underlying issue may be a diffuse motility problem rather than fecal impaction, ultrasonographic use of the rectosigmoid index may be more informative in diagnosing and planning the treatment of constipation. Consequently, informing the child and family with objective US measurements may provide positive support for the continuation of treatment. Furthermore, although evaluating changes in intestinal blood flow using Doppler ultrasound may not provide significant benefits in clinical practice for this patient group, it may offer valuable insights for future scientific research.

Funding:

None

Author Contribution

Neslihan Gulcin: Data collection,wrote the main manuscript text, prepared figuresSabriye Gulcin Bozbeyoglu:Data collectionArzu Canmemıs:Data collectionAll authors reviewed the manuscript

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Table 1

Symptoms of the patients
Symptoms	n (%)
Infrequent urination	1 (3,1)
Enurezis diurna	6 (18,8)
Enurezis nokturna	7 (21,9)
Urinary incontinence	9 (28,1)
Urinary and fecal intontinance	2 (6,3)
Poliuri	2 (6,3)
Recurrent IYE	5 (15,6)

Table 2

Comparison of pre-treatment and post-treatment values of the groups and BBD group
		Groups		Test statistics
		BBD	Healty	Test value	p value
R S	Before treatment	0,97 (0,76)	1,27 (0,44)	1,642	0,101^&
	After treatment	1,27 (0,65)	1,27 (0,44)	0,944	0,345^&
	z; p	2,099; 0,036	-
Aort psv	Before treatment	153,5 (67,00)	129,0 (57,0)	1,479	0,139^&
	After treatment	141,5 (71,75)	129,0 (57,0)	1,050	0,294^&
	z; p	0,442; 0,658	-
Aort PI	Before treatment	2,26 (1,11)	2,33 (1,18)	0,493	0,622^&
	After treatment	2,57 (1,20)	2,33 (1,18)	0,930	0,353^&
	z; p	1,440; 0,150	-
Aort RI	Before treatment	0,86 (0,15)	0,87 (0,12)	0,056	0,955^&
	After treatment	0,90 (0,12)	0,87 (0,12)	1,615	0,106^&
	z; p	1,853; 0,064	-
Çölyak PSV	Before treatment	181,0 (89,75)	192,0 (132,3)	1,064	0,287^&
	After treatment	183,0 (114,0)	192,0 (136,5)	0,755	0,451^&
	z; p	0,647; 0,518	-
Çölyak PI	Before treatment	1,59 (0,84)	1,64 (1,23)	0,578	0,564^&
	After treatment	1,65 (0,98)	1,64 (1,23)	0,498	0,619^&
	z; p	1,234; 0,217	-
Çölyak RI	Before treatment	0,76 (0,17)	0,80 (0,17)	0,712	0,477^&
	After treatment	0,79 (0,21)	0,80 (0,17)	0,635	0,525^&
	z; p	1,633; 0,102	-
SMV PSV	Before treatment	173,5 (67,25)	171,0 (106,3)	0,733	0,464^&
	After treatment	166,0 (74,00)	171,0 (106,3)	1,458	0,145^&
	z; p	0,804; 0,421	-
SMV PI	Before treatment	2,13 ± 0,78	2,28 ± 0,68	0,789	0,433^†
	After treatment	2,16 ± 0,62	2,28 ± 0,68	0,745	0,459^†
	t; p	0,148; 0,883	-
SMV RI	Before treatment	0,82 (0,11)	0,85 (0,10)	1,241	0,214^&
	After treatment	0,84 (0,11)	0,85 (0,10)	0,728	0,467^&
	z; p	0,606; 0,545	-
Data are given as mean ± standard deviation or median (interquartile range values), ^&: Mann-Whitney U test, ^†: Independent Samples t test, z: Wilcoxon test, t: Paired sample t test

Table 3

Comparison of pre-treatment and post-treatment values of the BBD group according to the R/S index in the patient group
		R/S index		Test statistics
		< 1 cm n = 20	≥ 1 cm n = 12	Test value	p value
Aort PSV	Before treatment	149,00 (86,75)	158,00 (56,25)	0,312	0,774^&
	After treatment	141,50 (71,00)	148,00 (75,50)	0,623	0,552^&
	z; p	0,523; 0,601	0,089; 0,929
Aort PI	Before treatment	2,26 (1,08)	2,26 (1,23)	0,642	0,526^&
	After treatment	2,51 (1,18)	2,60 (1,18)	0,662	0,526^&
	z; p	1,232; 0,218	0,706; 0,480
Aort RI	Before treatment	0,86 (0,17)	0,86 (0,14)	0,215	0,833^&
	After treatment	0,91 (0,13)	0,87 (0,08)	1,248	0,224^&
	z; p	1,924; 0,054	0,275; 0,783
Çölyak PSV	Before treatment	194,50 (91,50)	137,50 (95,25)	2,569	0,009^&
	After treatment	189,00 (101,00)	163,00 (145,25)	0,243	0,826^&
	z; p	0,302; 0,763	1,295; 0,195
Çölyak PI	Before treatment	1,50 (0,79)	1,67 (1,20)	0,487	0,632^&
	After treatment	1,93 (1,07)	1,65 (1,10)	0,426	0,675^&
	z; p	1,328; 0,184	0,314; 0,754
Çölyak RI	Before treatment	0,75 (0,18)	0,80 (0,14)	0,604	0,552^&
	After treatment	0,78 (0,21)	0,80 (0,25)	0,203	0,857^&
	z; p	1,042; 0,298	1,217; 0,224
SMV PSV	Before treatment	177,50 (74,75)	173,50 (51,00)	0,175	0,863^&
	After treatment	159,50 (84,00)	180,50 (74,00)	0,428	0,687^&
	z; p	0,971; 0,332	0,157; 0,875
SMV PI	Before treatment	1,94 ± 0,69	2,47 ± 0,84	1,972	0,058^†
	After treatment	2,19 ± 0,69	2,11 ± 0,49	0,398	0,694^†
	t; p	1,366; 0,188	1,322; 0,213
SMV RI	Before treatment	0,80 (0,20)	0,84 (0,11)	1,598	0,116^&
	After treatment	0,85 (0,12)	0,83 (0,10)	0,781	0,454^&
	z; p	1,530; 0,126	1,482; 0,138
Data are given as mean ± standard deviation or median (interquartile range values), ^&: Mann-Whitney U test, ^†: Independent Samples t test, z: Wilcoxon test, t: Paired sample t test

No competing interests reported.

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Evaluation of Splanchnic Blood Flow Using Doppler Ultrasound Before and After Constipation Treatment in Patients with Bladder and Bowel Dysfunction

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INTRODUCTION

MATERIALS AND METHODS

STATISTICAL ANALYSIS

RESULTS

DISCUSSION

CONCLUSION

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Author Contribution

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