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作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　December 22, 2009 — 根據12月小兒科期刊(Pediatrics)中的一篇隨機控制試驗結果，灌腸和口服緩瀉劑對於治療功能性孩童便秘的直腸糞便嵌塞(rectal fecal impaction，RFI)一樣有效。
　　
　　荷蘭阿姆斯特丹學院醫學中心的Noor-L-Houda Bekkali醫師等人寫道，雖然缺乏科學資料，直腸灌腸一直被視為RFI的最佳第一線治療，兩篇研究顯示，口服聚乙二醇[polyethylene glycol (PEG)]治療獲得95%的成功去除阻塞。這是首次採用前瞻性隨機控制試驗，評估直腸灌腸或口服緩瀉劑用於便秘導致嚴重RFI孩童的效果。
　　
　　這項研究檢視的假設是，灌腸和PEG對於治療RFI應該一樣有效，但是灌腸耐受比較不好，去除阻塞時的結腸通過時間(colonic transit time，CTT)將可改善。
　　
　　研究樣本包括90名孩童(來自95名適合的孩童)，年紀4-16歲，有功能性便秘和RFI。進行直腸檢查和第一次CTT評估，在去除阻塞前一週紀錄便秘症狀。RFI病患被隨機指派每天一次的灌腸或使用PEG (1.5 g/kg/天)，連續6天。
　　
　　治療期間時進行第2次CTT測量，也進行孩童的行為問卷。其他結果包括成功的直腸去除阻塞、解便頻率以及大便失禁、腹部疼痛和水便等。
　　
　　平均年紀為7.5 ± 2.8歲，90人中有60名男孩；46人被指定以灌腸治療，44人指定使用PEG，每組各有5人退出。灌腸組的去除阻塞成功率為80%，PEG組為68%(P = .28)。
　　
　　雖然PEG組比較常發生大便失禁和水便(P < .01)，兩組的解便頻率(P = .64)、腹痛(P = .33)、行為分數以及CTT正常化(P = .85)等相似。
　　
　　研究作者寫道，灌腸和PEG對於治療孩童RFI有同樣的效果，相較於灌腸，PEG引起較多的大便失禁，行為分數相當。這些治療都可以視為RFI的第一線治療。
　　
　　研究限制包括可能有關於害怕行為之發現的干擾因素，只有在去阻塞之後才評估行為分數。
　　
　　研究作者結論表示，因為兩組的行為相當，以灌腸去除阻塞不一定被保留作為預防焦慮用，我們在灌腸組並未發現較多的害怕行為，這或許是因為在家中由父母親進行灌腸，而不是如一般在醫院等不熟悉環境中由護士執行。
　　
　　研究作者皆宣告沒有相關財務關係。


Enemas, Oral Laxatives Equally Effective for Childhood Fecal Impaction

By Laurie Barclay, MD
Medscape Medical News

December 22, 2009 — Enemas and orally administered laxatives are equally effective in treating rectal fecal impaction (RFI) in functional childhood constipation, according to the results of a randomized controlled trial reported in the December issue of Pediatrics.

"Despite a lack of scientific data, rectal enemas have long been advocated as the best first-line treatment for RFI," write Noor-L-Houda Bekkali, MD, from Academic Medical Centre in Amsterdam, Netherlands, and colleagues. "Two studies showed that oral [polyethylene glycol (PEG)] treatment yielded 95% successful disimpaction....This is the first prospective, randomized, controlled trial evaluating disimpaction with either rectal enemas or orally administered laxatives for children with severe RFI attributable to constipation."

The hypothesis tested by this study was that enemas and PEG would be equally effective in treating RFI but that enemas would be less well tolerated and colonic transit time (CTT) would improve during disimpaction.

The study sample consisted of 90 children (from 95 who were eligible), aged 4 to 16 years, with functional constipation and RFI. Rectal examination and first CTT measurement were performed, and symptoms of constipation were recorded 1 week before disimpaction. Patients with RFI were randomly assigned to treatment with once-daily enemas or with PEG (1.5 g/kg per day) for 6 consecutive days.

A second CTT measurement was performed during this treatment, as well as a child's behavior questionnaire. Other outcomes included successful rectal disimpaction, frequencies of defecation and fecal incontinence, and presence of abdominal pain and watery stools.

Mean age was 7.5 ± 2.8 years. Of the 90 participants, 60 were boys; 46 were assigned to enema treatment and 44 to PEG, with 5 dropouts in each group. Disimpaction was successful in 80% of patients in the enema group and 68% of the PEG group (P = .28).

Although fecal incontinence and watery stools occurred more often in the PEG group (P < .01), both groups had similar frequency of defecation (P = .64), abdominal pain (P = .33), behavior scores, and CTT normalization (P = .85).

"Enemas and PEG were equally effective in treating RFI in children," the study authors write. "Compared with enemas, PEG caused more fecal incontinence, with comparable behavior scores. The treatments should be considered equally as first-line therapy for RFI."

Limitations of this study include possible confounding of findings regarding fearful behavior and evaluation of behavior scores only after the start of disimpaction.

"Given the comparable behavior in the 2 groups, disimpaction with enemas should not necessarily be withheld to prevent anxiety," the study authors conclude. "We did not find more fearful behavior in the enema group, which might be explained by the administration of enemas by parents at home instead of by nurses in an unfamiliar environment (hospital), which is more common in practice."

The study authors have disclosed no relevant financial relationships.

Pediatrics. 2009;124:e1108-e1115.