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Journal of Pediatric Gastroenterology & Nutrition:
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The Paris Consensus on Childhood Constipation Terminology (PACCT) Group

Benninga, Marc PhD, MD1; Candy, David C.A MB, BS, MD, MSc, FRCP, FRCPCH2; Catto-Smith, Anthony G MD, FRACP, MRCP3; Clayden, Graham MD, FRCP, FRCPCH4; Loening-Baucke, Vera MD5; Lorenzo, Carlo Di MD6; Nurko, Samuel MD, MPH7; Staiano, Annamaria MD8

Section Editor(s): Finkel, Yigael M.D., Ph.D., ESPGHAN; Alonso, Estella M.D., NASPGHAN; Rosenthal, Philip M.D., NASPGHAN

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1Amsterdam, Netherlands

2Chichester, UK

3Parkville, Victoria, Australia

4London, UK

5Iowa City, Iowa, USA

6Columbus, Ohio, USA

7Boston, Massachusetts, USA

8Naples, Italy

It is the distinct impression of pediatricians world-wide that constipation is replacing persistent diarrhea in their daily workload (1). Precise data are difficult to obtain, in part due to differing definitions (2). The Pediatric Rome II criteria define defecation disorders based on presenting symptoms (3). Some pediatric gastroenterologists have found the current Rome criteria too restrictive (4-6). If robust, multicenter or even multinational studies are to be conducted to improve the understanding and treatment of constipation, then consensus on the definitions of pediatric defecation disorders is essential. For example, when reading an article on encopresis, one can never be sure whether the author is describing involuntary or intentional passage of stools in inappropriate places. A group of pediatric gastroenterologists and pediatricians with an interest in GI motility, gathered at the 2nd World Congress of Pediatric Gastroenterology, Hepatology and Nutrition in Paris in July 2004 to seek a consensus on childhood constipation terminology (PACCT).

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The aims of the PACCT Group

The aims of the PACCT Group were to reach consensus and define the terms used in childhood functional gastrointestinal disorders (including constipation) and to develop working definitions which might facilitate discussions on the Rome III Diagnostic Criteria for Childhood Functional Gastrointestinal Disorders. Consensus was reached when all members of the group accepted the definitions. The PACCT Group's discussions did not extend to diagnosis or treatment, or to the examination of the relative importance of the various conditions that constitute the clinical spectrum of constipation.

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Chronic constipation

The PACCT Group offered the following working definition for chronic constipation in children, which would include untreated patients and children receiving treatment who still fulfil the criteria. Chronic constipation is defined as:

The occurrence of two or more of the following characteristics, during the last 8 weeks:

* Frequency of bowel movements less than three per week

* More than one episode of fecal incontinence per week

* Large stools in the rectum or palpable on abdominal examination

* Passing of stools so large that they obstruct the toilet

* Retentive posturing and withholding behavior

* Painful defecation

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Fecal Incontinence

The PACCT Group suggested that the term functional fecal retention is redundant as it is included in the above definition of chronic constipation. The PACCT Group also recommended that use of the following general terms be discontinued and replaced by the term incontinence:

* Soiling - often used interchangeably with encopresis. This term is not precise enough for trial definitions, as it can occur in the absence of constipation, can be both voluntary and involuntary, and is a pejorative term in some cultures connoting dirtiness and blame

* Encopresis - a term with widely varying usage and connotation. Physicians in some parts of Europe use encopresis to describe the passage of a normal stool in a socially inappropriate place (a rare event often associated with psychologic disorder). Practitioners in the USA may use the term interchangeably with fecal soiling or fecal incontinence.

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Fecal incontinence

The PACCT group suggested that the term fecal incontinence should be adopted in place of the terms encopresis and soiling, and offered the following definition: passage of stools in an inappropriate place. Fecal incontinence may be a result of either:

* Organic fecal incontinence e.g. resulting from neurologic damage or anal sphincter abnormalities, or

* Functional fecal incontinence, which can be sub-divided into:

* Constipation-associated fecal incontinence

* Non-retentive fecal incontinence

Chronic fecal incontinence, defined in the terms above, would be diagnosed if symptoms had present for at least least eight weeks.

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Non-retentive fecal incontinence

Non-retentive fecal incontinence, was defined by the PACCT Group as: The passage of stools in an inappropriate place by a child with a mental age of 4 years and older, with no evidence of constipation by history and / or examination.

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Fecal impaction

The PACCT Group offered the following definition for fecal impaction: Severe constipation with a large fecal mass in either the rectum or the abdomen, which is unlikely to be passed on demand. Fecal impaction can include a dilated rectum filled with stool, or a large amount of (usually) hard stool noted as an abdominal fecal mass (an obstructive fecaloma) either by rectal examination or abdominal palpation. It may also be identified by abdominal radiograph, ultrasound or other methodologies.

Defining fecal impaction by the volume of stool alone is a problem, as different examiners apply different subjective definitions to abnormal volume. There is no standard method of measuring actual stool volume outside the clinic setting. Even regularly used terms to suggest large volume, such as ‘stools large enough to obstruct the toilet’ present difficulties, as there is are no international standards for the calibre of household plumbing. However, as all children will have difficulty in passing an impacted stool spontaneously, the inclusion of this as a cardinal differentiating feature is recommended.

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Pelvic floor dyssynergia

The purpose of PACCT was to address issues relating to terminology; it was not to debate the relative importance of conditions associated with constipation. It was the PACCT Group's opinion that the term anismus should be dropped from the use in describing childhood constipation. The PACCT Group recommend that the term pelvic floor dyssynergia be used instead of anismus, as the former better describes the physiological process, and because of connotations of sexual abuse associated with the latter.

The PACCT Group offered the following definition of pelvic floor dyssynergia: Inability to relax the pelvic floor when attempting to defecate. This condition is characterized by lack of sphincteric relaxation while attempting to defecate; or by abnormal contraction of the pelvic floor during defecation. Lack of sphincter relaxation is sometimes seen as an abnormal contraction. These definitions are summarized in Table 1.

Table 1
Table 1
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Acknowledgments

The meeting was sponsored by Norgine UK Ltd, and facilitated by Phil Yates, of Coachwise UK, Beverley Evans and Christine Chapman of Athena Medical PR UK, and Mike Geraint and Julie Hornby Winfield of Norgine UK.

The PACCT Group consisted of the following pediatric gastroenterologists and pediatricians with an interest in GI motility:

Marc Benninga, PhD, MD

Amsterdam, Netherlands

David C.A. Candy, MB, BS, MD, MSc, FRCP, FRCPCH

Chichester, UK

Anthony G. Catto-Smith, MD, FRACP, MRCP

Parkville, Victoria, Australia

Graham Clayden, MD, FRCP, FRCPCH

London, UK

Vera Loening-Baucke, MD

Iowa City, Iowa, USA

Carlo Di Lorenzo, MD

Columbus, Ohio, USA

Samuel Nurko, MD, MPH

Boston, Massachusetts, USA

Annamaria Staiano, MD

Naples, Italy

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References

1. Guiraldes E. Pediatric Gastroenterology in Chile - a personal perspective. J Pediatr Gastroenterol Nutr 2002;33:231-2.

2. Sonnenberg A, Koch TR. Physician visits in the United States for constipation: 1958 to 1986. Dig Dis Sci 1989;34:606-11.

3. Rasquin-Weber A, Hyman PE, Cucchiara S, Fleisher DR, Hyams JS, Milla PJ et al. Childhood functional gastrointestinal disorders. Gut 1999;45 Suppl II:1160-8.

4. Nurko S. Advances in the management of pediatric constipation. Curr Gastroenterol Rep 2000;2:234-40.

5. Loening-Baucke V. Functional fecal retention with encopresis in childhood. J Pediatr Gastroenterol Nutr 2004;38:79-84.

6. Voskuijl WP, Heijmans J, Heijmans HS, Taminiau JA, Benninga MA. Use of Rome II criteria in childhood defecation disorders: applicability in clinical and research practice. J Pediatr 2004;145:213-7.

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