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Tachykinins in the gut. Part II. Roles in neural excitation, secretion and inflammation.

The preprotachykinin-A gene-derived peptides substance (substance P; SP) and neurokinin (NK) A are expressed in intrinsic enteric neurons, which supply all layers of the gut, and extrinsic primary afferent nerve fibers, which innervate primarily the arterial vascular system. The actions of tachykinins on the digestive effector systems are mediated by three different types of tachykinin receptor, termed NK1, NK2 and NK3 receptors. Within the enteric nervous system, SP and NKA are likely to mediate, or comediate, slow synaptic transmission and to modulate neuronal excitability via stimulation of NK3 and NK1 receptors. In the intestinal mucosa, tachykinins cause net secretion of fluid and electrolytes, and it appears as if SP and NKA play a messenger role in intramural secretory reflex pathways. Secretory processes in the salivary glands and pancreas are likewise influenced by tachykinins. The gastrointestinal arterial system may be dilated or constricted by tachykinins, whereas constriction and an increase in the vascular permeability are the only effects seen in the venous system. Various gastrointestinal disorders are associated with distinct changes in the tachykinin system, and there is increasing evidence that tachykinins participate in the hypersecretory, vascular and immunological disturbances associated with infection and inflammatory bowel disease. In a therapeutic perspective, it would seem conceivable that tachykinin antagonists could be exploited as antidiarrheal, antiinflammatory and antinociceptive drugs.

Animals↗

Lectins in fruits having gastrointestinal activity: their participation in the hemagglutinating property of Escherichia coli O157:H7.

BACKGROUND: In fruits with therapeutic properties for antidiarrheal and laxative uses, the presence of lectins may be the bioactive properties that interfere with bacterial adhesion, thought to be competition for glycoside signal sites in the attachment. METHODS: This study identifies lectins in crude extracts from fruits such as Tamarindus indica (tamarind), Spontia vulgaris (plum), Psidium guava (guava), Mangifera indica (mango), Cydonia vulgaris (quince), and Crataegus mexicanus (tejocote). To verify the procedures, extracts from Ricinus communis (castor bean), Glycine max (soybean), Phaseolus vulgaris (beans), Vicia fava (fava bean), and Solanum tuberosum (potato) were used as controls for lectin activity. Both sources of lectins were analyzed to determine their participation in the host-parasite interaction, using as a model the hemagglutinating properties of Escherichia coli O157:H7 (EHA). RESULTS: All extracts showed hemagglutination to group O erythrocytes test (HA) with the exception of mango. Two new galactose-specific lectins were identified from tamarind and guava. When analyzed for participation in EHA, only guava lectins inhibited this, while soybean lectin induced hemolysis; as both lectins bind to galactose, it is probable that their recognition occurs in different domains. Sugars involved in the attachment between Escherichia coli O157:H7 and red cells were identified and again, galactose in addition to mannose was found to be related in EHA. On the other hand, guava lectins also agglutinated E. coli O157:H7, perhaps due to the same galactose-specific lectin or to another type of lectin. CONCLUSIONS: In summary, guava has a galactose-specific lectin that prevents adhesion of E. coli O157:H7 to red cells; this lectin is mediated by galactose. Prevention could also be due to their capacity of agglutinating E. coli by guava lectins. Soybean lectin induced hemolysis only when bacteria was present, but not with floating secretions. This finding showed that guava is a source of lectin that can be explored to prevent adhesion of E. coli to epithelial intestinal cells; contrariwise, soya must be studied to see its participation in the uremia caused during E. coli O157:H7 pathogenesis.

Bacterial Adhesion↗

Toxicoses from over-the-counter human drugs.

This article describes the mechanisms, recognition, and management of toxicoses from human over-the-counter (OTC) drugs. Drugs that have been included were chosen because of their potential for toxicosis and the incidence of exposure. Drug groups discussed are cough, cold, and allergy medications, laxatives and cathartics, antacids, antidiarrheal agents, topicals, and vitamin and iron supplements.

Animals↗

Circulating levels of transforming growth factor-beta1 and lymphokines among children with hemolytic uremic syndrome.

Verotoxin-producing Escherichia coli (VTEC) cause hemorrhagic colitis (HC) and hemolytic uremic syndrome (HUS). The aim of this study was to compare the circulating levels of transforming growth factor-beta 1 (TGF-beta1), T helper (T(H))1 (interferon [IFN]-gamma, interleukin [IL]-2), and T(H)2-associated lymphokines (IL-4, IL-13) in children with uncomplicated Escherichia coli O157:H7 HC and patients who developed HUS. Circulating levels of IL-2, IL-4, and IL-13 were undetectable, and those of IFN-gamma were low and comparable among groups. Concentrations of TGF-beta1 were higher in children with uncomplicated O157:H7 HC than among those who developed HUS (934 +/- 680 versus 514 +/- 497 pg/mL, respectively; P < 0.04). The circulating levels of TGF-beta1 were also higher among children who did not take antidiarrheal agents (P < 0.008) and those who have been immediately discharged from the emergency room (P < 0.03). Our results did not show an imbalanced T(H)1/T(H)2-associated lymphokine response during the development of HUS. Increased circulating levels of TGF-beta1 in children with milder O157:H7 or uncomplicated HC most likely reflect appropriate intestinal tissue repair mechanisms rather than a remote systemic endocrine effect on the kidneys.

Adolescent↗

Physicians' prescribing behaviour for diarrhoea in children: an ethnoepidemiological study in Southern Brazil.

With the aim of implementing an intervention program on physician's prescribing behaviour for diarrhoea in children under five, an ethnoepidemiological study was conducted in Pelotas (Brazil), from February to April 1993. Information on prescription of drugs was obtained through record review of 381 cases of diarrhoea provided by 33 medical doctors from eight health centres. Trained field workers observed a total of 54 clinical consultations due to diarrhoea. Brief exit interviews with the mothers were performed just after the observations. Twenty-seven open-ended home interviews were made with the mothers the day after they had been observed. After all observations had been completed, open-ended interviews were conducted with 21 physicians. The results showed that there is a misunderstanding of the role of ORS in the treatment of diarrhoea: mothers want something to "cut" diarrhoea and they notice that ORS does not act in this way and doctors do not explain the action of ORS in diarrhoea management. Comparing with record reviews, during observations a child had a lower probability of receiving an antibiotic or antidiarrheal drug prescription. This finding indicates that other variables than technical skills are involved in doctor's prescribing behaviour. A lack of ability or of motivation to deal with "anxious or difficult mothers" led some doctors to enhance antibiotic or other non-recommended drugs to manage diarrhoea. Therefore, efforts to improve the quality of case management of diarrhoea, through intervention programmes in the government health sector, are needed in Pelotas.

Brazil↗

Intensity-modulated whole pelvic radiotherapy in women with gynecologic malignancies.

PURPOSE: To describe our initial clinical experience with intensity-modulated whole pelvic radiotherapy (IM-WPRT) in women with gynecologic malignancies. METHODS AND MATERIALS: Between February 2000 and August 2001, 40 gynecology patients underwent IM-WPRT. After fabrication of customized immobilization, all patients underwent contrast-enhanced CT, and a clinical target volume was contoured consisting of the upper vagina, parametria, uterus (if present), and presacral and pelvic lymph node regions. The clinical target volume was expanded by 1 cm to create a planning target volume (PTV). Using commercially available software, 7- or 9-field, 6-MV, coplanar IM-WPRT plans were generated for all patients. The worst acute gastrointestinal and genitourinary toxicity during treatment was scored on a 4-point scale: 0, none; 1, mild, no medications required; 2, moderate, medications required; and 3, severe, treatment breaks or cessation, hospitalization. As a comparison, acute toxicities in 35 previously treated conventional WPRT patients were analyzed. No significant differences were noted in the clinicopathologic and treatment factors between the two groups. RESULTS: IM-WPRT plans provided excellent PTV coverage, with considerable sparing of the surrounding normal tissues. On average, 98.1% of the PTV received the prescription dose. The average percentage of the PTV receiving 110% and 115% of the prescription dose was 9.8% and 0.2%, respectively. IM-WPRT was well tolerated, with no patient developing Grade 3 toxicity. Grade 2 acute gastrointestinal toxicity was less common in the IM-WPRT group (60 vs. 91%, p = 0.002) than in the conventional WPRT group. Moreover, the percentage of IM-WPRT and WPRT patients requiring no or only infrequent antidiarrheal medications was 75% and 34%, respectively (p = 0.001). Although less Grade 2 genitourinary toxicity was seen in the IM-WPRT group (10% vs. 20%), this difference was not statistically significant (p = 0.22). CONCLUSION: IM-WPRT is a promising approach in gynecology patients. IMRT planning resulted in excellent PTV coverage, with considerable sparing of normal tissues. Treatment was well tolerated and associated with less acute gastrointestinal sequelae than conventional WPRT. Longer follow-up and more patients are needed, however, to evaluate the full merits of this novel approach.

Adult↗

American Brachytherapy Society recommendations for reporting morbidity after prostate brachytherapy.

PURPOSE: To standardize the reporting of brachytherapy-related prostate morbidity to guide ongoing clinical practice and future investigations. METHODS: Members of the American Brachytherapy Society (ABS) with expertise in prostate brachytherapy performed a literature review and, guided by their clinical experience, formulated specific recommendations for reporting on morbidity related to prostate brachytherapy. RESULTS: The ABS recommends using validated, patient-administered health-related quality-of-life instruments for the determination of baseline and follow-up data regarding bowel, urinary, and sexual function. Both actuarial and crude incidences should be reported, along with the temporal resolution of specific complications, and correlated with the doses to the normal tissues. The International Prostate Symptom Score is recommended to assess urinary morbidity, and any dysuria, gross hematuria, urinary retention, incontinence, or medication use should be quantified. Likewise, the "Sexual Health Inventory for Men," which includes the specific erectile questions of the International Index of Erectile Function, is the preferred instrument for reporting sexual function, and the loss of sexual desire, incidence of hematospermia, painful orgasm (orgasmalgia), altered orgasm intensity, decreased ejaculatory volume, use of erectile aids, and use of hormones for androgen deprivation should be quantified. The ABS recommends adoption of the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer acute and late radiation morbidity scoring scheme for reporting rectal morbidity and noting the incidence of rectal steroid, laser, or antidiarrheal use. CONCLUSION: It is important to focus on health-related quality-of-life issues in the treatment of prostate cancer, because the control rates are very similar between appropriate treatment modalities. The ABS recommends using the International Prostate Symptom Score, International Index of Erectile Function, and Radiation Therapy Oncology Group toxicity grading criteria for the determination of urinary, sexual, and bowel function, respectively. Additional parameters for reporting urinary, rectal, and sexual morbidities are presented. These morbidities should be correlated with the doses to the normal tissues. Some of these specific recommendations may be modified if and when new data become available.

Brachytherapy↗

The correlation of acute toxicity and late rectal injury in radiotherapy for cervical carcinoma: evidence suggestive of consequential late effect (CQLE).

PURPOSE: To correlate the acute toxicity during pelvic irradiation and the development of late rectal injury following radiation therapy for cervical carcinoma. METHODS AND MATERIALS: Two hundred and twenty patients treated with curative-intent radiation therapy between November 1987 and January 1992 were analyzed. Patients were treated initially with external beam irradiation, 40-44 Gy/20-22 fractions to whole pelvis, followed by high dose rate intracavitary brachytherapy, 7.2 Gy to point A for 3 fractions. Severity of diarrhea during radiation therapy was scored according to six criteria: fecal characteristics, frequency, onset, prescription of antidiarrheal agents, body weight loss during irradiation, and extramedical care needed. Patients were categorized as group ND (no obvious diarrhea), group MD (moderate diarrhea), and group SD (severe diarrhea) for sum score 0-1, 2-5, and > or = 6, respectively. The rate of radiation proctitis was expressed, analyzed, and compared with actuarial proctitis-free rate and prevalence. RESULTS: 1) According to the score, 76 (35%), 89 (40%), and 55 (25%) patients were categorized as group ND, group MD, and group SD, respectively. Distribution of patients and treatment characteristics among the three groups appeared similar. Patients treated with a larger field size, > or = 16.5 cm2, tended to have increased severity of diarrhea. 2) Overall, 103 patients (47%, 103 of 220) developed radiation proctitis. Twenty-one patients were in group ND (28%, 21 of 76), 43 in group MD (48%, 43 of 89), and 39 in group SD (71%, 39 of 55). 3) The five-year actuarial proctitis-free rate was 72, 52, and 29% for group ND, MD, and SD, respectively (p < 0.005). 4) Taking time evolution and recoverability into account, the effect of diarrhea on the prevalence of radiation proctitis remained statistically significant at the first through the fourth year after irradiation. 5) Severity of radiation proctitis and severity of diarrhea were not correlated (Spearman's rank correlation coefficient r(s) = 0.229, p = 0.098). 6) Cox's multivariate analysis revealed that severity of diarrhea was the only factor that significantly correlated with the development of radiation proctitis. CONCLUSION: Patients with increased acute toxicity and diarrhea during radiation therapy of cervical carcinoma significantly increased the risk of late rectal injury. This result suggested that early excessive damage of acute-responding component of rectal wall may play an important role in the initiation of late rectal injury. Radiation proctitis can be accounted, in part, as a consequential late effect.

Adult↗

The emergency department approach to diarrhea.

Enteric disease represents a significant medical problem on a worldwide basis. The evaluation of patients with diarrhea in the emergency department should follow a stepwise methodology to identify potentially serious disorders. The evaluation of the stool for fecal leukocytes is an important differentiation point in the evaluation of the moderately to seriously ill diarrhea patient. Oral rehydration alone can treat the vast majority of diarrhea patients. Oral rehydration solution takes advantage of the sodium glucose coupled active absorption mechanism, which is largely unaffected by enteric toxins. Antimicrobial or antidiarrheal agents are rarely indicated in the treatment of diarrhea.

Diarrhea↗

Severe acute diarrhea.

Acute diarrhea is commonly caused by an infection. Severe acute diarrhea warrants immediate medical evaluation and hospitalization. Indications for stool studies include fever; bloody diarrhea; recent travel to an endemic area; recent antibiotics; immunosuppression; and occupational risks, such as food handlers. Noninfectious causes include inflammatory bowel disease, radiation enteritis, and intestinal ischemia. Management of severe acute diarrhea includes intravenous fluid rehydration and empiric antibiotics. Use of antidiarrheal agents is controversial when invasive pathogens are suspected.

Acute Disease↗

[Hemolytic-uremic syndrome: microbiological aspects].

Escherichia coli O157: H7 became an important pathogen starting in the early 1980s. It has caused epidemics and sporadic cases of often bloody diarrhea which may progress to severe hemolytic and uremic syndrome or thrombotic thrombocytopenia purpura. E. coli O157: H7 is mainly transmitted in food, water and interhuman transmission, but direct animal-to-man transmission has also been documented. E. coli O157: H7 can adhere tightly to the enterocyte brush border (eae gene) and produce verotoxins or Shiga-like toxins and hemolysine (ehxA gene). Diagnosis of E. coli O157: H7 infections is based on evidencing the germ in stools and/or by identifying the genes coding for verotoxins or by serology which increased serum titre of specific antilipopolysaccharide antibodies. Antidiarrheal drugs and antibiotics have little place in the treatment of bloody diarrhea. This public health problem, requires careful identification of animal reservoirs and improved population education in food hygiene.

Animals↗

Evaluation of scheduled J-pouch irrigations on decreasing stool frequency after ileoanal pull-through and ileostomy closure.

This study was intended to determine whether J-pouch irrigations through the efferent limb of the protective ileostomy stoma after ileoanal pull-through are effective in decreasing high stool frequency after ileostomy closure. Patients undergoing ileoanal pull-through may have high stool frequency after ileostomy closure. J-pouch irrigations through the efferent ileostomy stoma may decrease stool frequency by increasing J-pouch volume, improving storage capacity. The study used a randomized, prospective design in a university hospital outpatient setting. Participants (N = 58) were randomly assigned to control and experimental groups. Effectiveness of irrigation was determined by stool frequency. Both groups were taught Kegel exercises (anal muscle strengthening exercises). The experimental group was taught how and when to irrigate the J-pouch daily; the control group was not. Forty-seven subjects, 25 men and 22 women ranging in age from 15 to 65 years, completed the study. Results of MANOVA indicated no significant between-group difference in the average number of times that subjects performed Kegel exercises; however, there was a significant decrease during the 4-week study period (p < 0.001). There was no significant difference between groups in stool frequency, which decreased with time. There also was no significant effect on nocturnal leakage or satisfaction with surgical outcome. Additional clinical variables that were measured but had no significant effect included eating late, pouch size, and intake of sugar, fiber, bulk-forming products, and antidiarrheal agents. The study did not support the effectiveness of J-pouch irrigation in decreasing stool frequency after ileostomy closure. The cost, time commitment, and burden of performing daily irrigations are not warranted in this patient group.

Adult↗

Small bowel review: normal physiology part 1.

In the past year there have been many advances in the area of small bowel physiology and pathology and therapy. In preparation for this review, over 1500 papers were assessed. The focus is on presenting clinically useful information for the practising gastroenterologist. Selected important clinical learning points include the following: (1) glucose absorption mediated by SGLT1 is controlled by mRNA abundance, as well as by posttranscriptional processes including protein trafficking; (2) inducers of cytochrome P-450 decrease glucose and fructose absorption and increase glucose consumption in the intestine; (3) the regulated release of nutrients from the stomach into the upper intestine ensures that the modest intestinal transport reserve capacity is not exceeded; (4) hepatocyte growth factor and short-chain fatty acids may enhance intestinal adaptation and prevent the atrophy seen when total parenteral nutrition is infused; (5) inhibitors of pancreatic lipase and phospholipase H2 may be useful clinically to reduce absorption as part of a treatment program for obesity and hyperlipidemia; (6) several membrane-bound and cytosolic proteins have been identified in the enterocyte as well as in the hepatocyte and may be the target for the future therapeutic manipulation of bile acid metabolism and control of hyperlipidemia; (7) suspect bile acid malabsorption in the patient with otherwise unexplained chronic diarrhea; (8) a proportion of lipid absorption is protein-mediated, and this opens the way to targeting these proteins and thereby therapeutically modifying lipid absorption; (9) a high protein diet may be useful to increase the intestinal absorption of drugs transported by the H+/dipeptide cotransporter; (10) a metal transporter DCT1 has been identified, and this may open the way to a better understanding of disorders of, for example, iron and zinc metabolism; (11) the nutrient transporters such as SGLT1 are responsible for a portion of the intestinal absorption of water; (12) the influence of nitric oxide on intestinal water absorption and secretion depends on its concentration; (13) a trial of bile acid-sequestering agent may prove useful in the treatment of the patient who experiences diarrhea while taking an enteral diet; (14) a proteolytic extract from pineapple stems may prove to be useful to treat diarrhea, although the mechanism of this effect remains to be established; and (15) the antisecretory effect of the new peptide, sorbin, needs to be tested in a clinical situation on patients with diarrhea. Other new and promising antidiarrheal agents include bromelain, an extract from pineapple stems, and igmesine, a final sigma ligand.

Acute-Phase Proteins↗

Delta-opioid receptor mRNA expression and immunohistochemical localization in porcine ileum.

Opiates have potent antidiarrheal actions that are mediated in part by delta-opioid receptors (DOR). We examined DOR localization within subregions of porcine ileum, a tissue analogous to human small bowel. A partial cDNA sequence for porcine DOR was obtained after reverse transcription-polymerase chain reaction cloning of forebrain RNA; it encoded the end of transmembrane domain 1 through the beginning of transmembrane domain 7 and exhibited 93% nucleotide identity with human DOR. Positive signals for DOR mRNA were found in all subregions of the porcine ileal wall. With an antiserum recognizing an N-terminal epitope in murine DOR, DOR-like immunoreactivity was localized in neurons within myenteric and submucous ganglia, longitudinal and circular smooth muscle, and villous lamina propria. The DOR agonist [D-Ser2, Leu5, Thr6]enkephalin (DSLET) attenuated circular smooth muscle contractions in porcine ileum that were evoked by electrical stimulation of myenteric cholinergic neurons. These results are consistent with previous reports of the DOR-mediated neuromodulation that underlies the antipropulsive and antisecretory effects of opioids in the intestinal tract.

Animals↗

Short-chain fatty acids inhibit fluid and electrolyte loss induced by cholera toxin in proximal colon of rabbit in vivo.

Short-chain fatty acids (SCFA), acetate, propionate, and butyrate, are produced by bacterial fermentation in the colon and stimulate Na+ and Cl- absorption. We have studied the effects of SCFA on fluid and electrolyte absorption during cholera toxin (CT) -induced colonic secretion in rabbit, using a steady-state perfusion technique with marker (PEG) dilution. Perfusion with SCFA significantly (P < 0.01) reduced colonic water secretion. Butyrate reduced water secretion the most (95%), followed by propionate (90%), and acetate (80%). Butyrate significantly (P < 0.001) reduced secretions of Na+ (95.5%), K+ (75.2%), and Cl-(80.7%) ions but not HCO3- ions. Propionate similarly reduced secretion of HCO3-(45.3%). Acetate significantly (P < 0.001) inhibited Na+ (76.4%) and Cl- (75.7%) secretion, but the inhibitions of K+ (23.6%) and HCO3 (28.8%) were not significantly different from the controls. We conclude that SCFA reduce CT-induced water and electrolyte secretion in the rabbit proximal colon, and its potential as an antidiarrheal agent should be further evaluated.

Acetic Acid↗

Somatostatin receptor subtype 2 mediates somatostatin inhibition of ion secretion in rat distal colon.

BACKGROUND & AIMS: Somatostatin peptides are potent inhibitors of intestinal ion secretion, providing the rationale for their use in treating secretory diarrhea. However, the nature of the receptors that mediate these effects is unclear. The aims of this study were to investigate expression of somatostatin receptor subtypes (SSTRs) 1-5 in rat colonic epithelium and to identify which subtype(s) mediate inhibition of adenosine 3', 5'-cyclic monophosphate (cAMP)-activated secretion using SSTR-selective analogues. METHODS: SSTR expression was determined by reverse-transcription polymerase chain reaction and immunoblotting. Effects of somatostatin analogues on electrogenic ion secretion were studied in isolated colonic mucosa mounted in Ussing chambers. RESULTS: Crypt epithelium expressed messenger RNA for SSTR1 and SSTR2 and low levels of SSTR5. A splice variant of SSTR2 (SSTR2B) was also detected. The SSTR2 selective analogue NC-812 was a potent inhibitor of forskolin-activated secretion and cAMP accumulation. In contrast, peptides selective for SSTR3 (DC-25/12) and SSTR5 (DC-23/99) were weak inhibitors of secretion. NC-812 also inhibited dibutyryl cAMP-activated secretion, indicating a site of action distal to cAMP production. Immunoblot analysis confirmed expression of a 93-kilodalton SSTR2 protein in crypt cell membranes. CONCLUSIONS: SSTR2 receptors expressed by colonocytes mediate somatostatin's antisecretory actions in rat colon. Somatostatin analogues directed to specific SSTRs may provide the basis for more selective antidiarrheal drugs.

Animals↗

Treatment of refractory microscopic colitis with azathioprine and 6-mercaptopurine.

Many patients with microscopic colitis will respond to antidiarrheal medications or to anti-inflammatory therapy with 5-aminosalicylates, although a few require corticosteroids. Some patients do not tolerate corticosteroid side effects, and a small subset are dependent on or refractory to corticosteroids. We report our experience with azathioprine and 6-mercaptopurine in patients with microscopic colitis.

Adult↗

Pathophysiology of pediatric fecal incontinence.

This article addresses the diagnosis and treatment of pediatric fecal incontinence in 4 main categories: (1) Functional fecal retention, the withholding of feces because of fear of painful defecation, results in constipation and overflow soiling. Treatment includes dietary changes, use of laxatives, and cognitive and behavioral interventions such as toilet training, which diminishes phobia and provides positive reinforcement through a rewards system. (2) For functional nonretentive fecal soiling (encopresis), antidiarrheal agents can increase the consistency of stools and facilitate continence. Anorectal biofeedback for children has been proposed, but its efficacy remains unproven. Parents should be educated to conduct nonaccusatory toilet training and help children alleviate guilt and enhance self-esteem. Appropriately constructed trials are necessary to gauge the effect of adding prolonged use of enemas to an intensive toilet training program. (3) Surgery can correct minor congenital anorectal anomalies by identifying the external sphincter, separating the rectum from the genitourinary tract, and reconstructing the anus. However, there is great variation in postsurgical functional outcomes for anorectal malformations. Double-blinded, randomized controlled trials could help define the role of appendicostomy, cecostomy, sphincter reconstruction, colostomy, and artificial sphincters. (4) Children with spina bifida and fecal incontinence may benefit from techniques that teach them how to defecate. A continent appendicostomy (Malone procedure) is a promising treatment that completely cleanses the colon, increases the child's autonomy, and decreases the chance of soiling. A cecostomy can be performed surgically, endoscopically, or radiologically to provide some of the same benefits.

Child↗