Measuring the Performance of Your Child's Digestive Muscles

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi, everyone. Welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the chair of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And I'm so pleased to have today, Dr. Ben Freiberg, who's a pediatric gastroenterologist at Cleveland Clinic Children's. And we're going to talk a little bit about measuring the performance of your child's digestive muscles. Ben, welcome to Butts & Guts.

Dr. Ben Freiberg: Thanks for having me here.

Dr. Scott Steele: So tell us a little bit about your background, where you’re from, where did you train and how did you come to the point that you're here at the Cleveland Clinic?

Dr. Ben Freiberg: I'm originally from the Boston area, grew up there and spent most of my time there. Did my medical school training at Boston University. Finally, left Boston to do my training in residency in pediatrics in Westchester. Did my training in gastroenterology at Yale and did an advanced year there as well in motility specifically. And as I was looking for positions, I saw the great opportunity here at The Clinic and took it.

Dr. Scott Steele: Well, I'm so glad you're here. And we're going to delve in a little bit later about a new procedure that's available here at Cleveland Clinic Children's, but first let's set the stage. So what is motility and specifically when we're talking about our GI system?

Dr. Ben Freiberg: So with motility, what we're talking about is how the GI tract is moving. So, as we all know, we eat. Food comes in through our mouth and then it goes through an entire process where food gets swallowed, goes down the food pipe, our esophagus, and enters into our stomach where it gets churned and digested, processed, and everything moves into the small intestine where it gets absorbed into our body. As it goes through that system, whatever remains ends up in our colon where water is taken out, turns into the poop that we produce and expel out.

Dr. Scott Steele: So what are some of the names of the common motility issues that people might have, and how common are GI motility issues in children?

Dr. Ben Freiberg: So starting from the top, we have issues where children have difficulty swallowing. We call that dysphagia. Then as it goes down into the food pipe, the food can sometimes get stuck there depending on the cause. That can be an inflammatory process or a disease called achalasia.

In the stomach, if we have a delay in the emptying of the stomach into the small intestine, that's called gastroparesis. And then with our small intestinal motility and our colonic motility, we just call that dysmotility for the small intestine or dysmotility for the colon. And typically with the colon, what we have is issues with constipation there.

And, in terms of how often we see it in children, so it's actually fairly common that we see children coming in with complaints of either difficulty swallowing, of belly pain that might be related to a little bit of dysmotility. But the most common thing that we do see in children is issues with constipation. I would say that's about a quarter to half of our pediatric population that we see in the office.

Dr. Scott Steele:

So like many of things that when people experience symptoms, they come in, they get evaluated, they get a history and physical and they may get a test. So walk us through this new test at Cleveland Clinic, what is colonic and antroduodenal manometry procedure.

Dr. Ben Freiberg:

So these are two separate tests. So with the antroduodenal, what we're looking for is what is the stomach and the beginning part of the small intestine doing, how effective they are. So we have little pressure sensors on a very long probe that we put in while the child is sleeping under anesthesia. And when they wake up, the probe is already in place and we can connect it to a computer where those little pressure sensors are monitored. And we see how they do when they're eating. And we give them medications that can help those muscles contract.

Similarly with the colon, a long probe with little pressure sensors are placed while the child is asleep. And in this case, we look to see what is the colon doing, how is the colon functioning, both after eating and with medications.

Dr. Scott Steele:

So why is this procedure so helpful in measuring the performance of digestive muscles?

Dr. Ben Freiberg:

Looking at each one individually, we really want to get a sense of what might be causing some of the symptoms. So with the upper, with antroduodenal, what we're looking for is to get a better understanding why the child might have a lot of nausea, why they're throwing up so much and see, is it that the muscles aren't fully contracting, that they're not fully pushing everything out and whether or not some of these medications can be helpful. Or is it more an issue where we need to work on the diet where the child might need to have smaller, more frequent meals that are smoother, that are a lot more easily to digest and can pass along through the intestines.

And with the colonic manometry, what we're really looking for is to evaluate children with constipation that have really failed medical therapies. So they've been on multiple medical regiments that haven't been doing well. They continue to struggle with constipation, having a bowel movement maybe once a week, once every other week. And we're really at that point of, do we need to do some sort of surgical intervention. So we really want to see is the child a candidate for surgery, or can we still push the medications and see if we can recover the colon.

Dr. Scott Steele:

So truth or myth, motility issues typically start during potty training.

Dr. Ben Freiberg:

As with everything, it's a combination actually. So what we often see is that particularly with constipation, children start to withhold. So early on in life, when you start introducing solid foods into their diet, when you're starting to introduce whole milk into the diet, you get the change in the makeup of the poop. And now the poop starts to become a little bit harder.

And as with any of us, we really don't want to experience pain. So they have a harder defecation. They have a harder bowel movement. It's very painful. And in order to avoid that, they start withholding. And that withholding process, that allows all the poop to just build up in the colon and the colon just stretches out like a balloon. Then what we see is that with potty training, children want to have that control over their body.

So again, you see that withholding behavior and as the poop starts to build up, the colon starts to blow up like a balloon. But thankfully with the medication therapy, we can ensure that the stools themselves are nice and soft and we can actually recover the colon to allow that colon to really shrink down and go back to a normal size so that they can have easy bowel movements.

As for the upper ones, those really can come about any time in life. So some children unfortunately are born with motility issues that affect the way that they swallow and affect the way that the food goes through the digestive tract, or can develop later on in life.

Dr. Scott Steele:

So you mentioned this a little bit briefly, but truth or myth, changes in diet can resolve these motility issues.

Dr. Ben Freiberg:

So if you catch it early on, dietary changes can be helpful particularly with constipation. What we find is that if you increase the amount of fiber, if you increase the amount of fluids, you trap that fluid in the poop that the child is making. And that can help soften the poop so that they're not struggling to have a bowel movement.

But if we try the diet and we see that that's not working, then we need to move on to some medical therapy to ensure that those bowel movements are nice and soft. And thankfully in most cases, you stay on the medications for a period of time. You slowly come off of them and then we can maintain the soft bowel movements with diets.

And in terms of the upper symptoms, that's more of making sure that the child is eating smaller portions, making sure that they're eating things that are more easily able to go down the food pipe and not having to digest the long period and easily kind of transition from the food pipe to the stomach, from the stomach to the small intestines.

Dr. Scott Steele: It's always stressful to go to the doctor's office. So what can a parent and their child expect during their appointment when they come to see you or another pediatric gastrologist here at Cleveland Clinic Children's?

Dr. Ben Freiberg: So, as you mentioned, the first step is really fact gathering. So we want to understand what's going on, how long has it been going on, what symptoms are present, whether it's the upper, whether it's lower, getting an understanding of how frequent the bowel movements are, what has been tried, what hasn't been tried and then the physical exam. So, looking at their belly, feeling their belly if it's soft or if there's any poop that we can feel inside.

Oftentimes, we do need to do a rectal exam, so we actually take a look at the child's bottom. We might need to put a finger inside to get some sense of how strong the muscles are or if there's any poop down in the rectal area. And going from there, we'll decide what sort of testing we need to do. So whether it's lab work, whether it's stool studies and whether it is these more invasive tests such as colonoscopy and endoscopy, or the antroduodenal manometry or colon manometry.

Dr. Scott Steele: So that's fantastic stuff. And so we always like to get to know our guests a little bit better. So what is your favorite food?

Dr. Ben Freiberg: That's a really good question. I actually have quite a few, so I'll kind of break it down based on entrées and desserts. So for me, I really love lasagna. Give me a good cheese lasagna, and ooh, I will devour the whole thing. And going along the lines of cheese, I really love a really good cheesecake.

Dr. Scott Steele: What is your favorite sport either to play or to watch?

Dr. Ben Freiberg: I enjoy following baseball and I actually enjoy playing baseball. I enjoy watching football a little more than watching baseball, but definitely those would be the two sports that I love the most.

Dr. Scott Steele: What is one of the favorite places that you've traveled to?

Dr. Ben Freiberg: I would have to say that would be London and it really wasn't a place that I traveled to. So, I was actually on a layover on the way home from a different trip, ended up staying there the night, right near Buckingham Palace. So that morning before my flight, I woke up, I ran to Buckingham Palace, did a nice little self-guided tour around that area. Then ran back, grabbed my stuff and went to the airport and flew back home. That's something I want to do again, spend a little bit more time and really explore the area.

Dr. Scott Steele: Great city, great area. Shameless plug for Cleveland Clinic London that is very close to Buckingham Palace. And then finally, what do you like about living here in Northeast Ohio?

Dr. Ben Freiberg: For me growing up in the Northeast, a lot of people say that New Englanders are really rough. And I would agree with that. Being in Ohio, everyone is so nice, so polite. You walk down the street, everyone is saying, "Hey, how are you doing?" I really love that. And the traffic, wow. It's just amazing to see the difference not being stuck in rush hour traffic, or rush hour traffic is having to wait on one additional light. That's about it.

Dr. Scott Steele: That's so true. So what's the final take home message that you can give to our listeners on this topic of motility and specifically your child's digestive muscles?

Dr. Ben Freiberg: So, you know, as with everything, definitely feel free to reach out to your pediatrician, to a GI provider with any questions. But the earlier that we start helping to manage these symptoms, the better we are at fixing them, the better we are at getting them to a point where we don't need to be on long-term medications.

So if particularly with constipation, if your child is struggling with constipation, you know, we try the diet. Definitely, don't be afraid of using some of these medications. These are not lifelong treatments that will need to keep the child on. We put them on for a few months, get them into a good place, slowly take them off. And they don't become dependent on these medications so that we don't need to kind of go to the more invasive tests and talking more about surgeries, things like that.

And similarly with children that are having difficulty swallowing, having difficulty with nausea and vomiting, definitely feel free to bring it up with your pediatrician, with your GI provider. Have these conversations with them in terms of what medications might be helpful and if we do need to do some of these additional testings.

Dr. Scott Steele:

So that's great words of wisdom. And so to learn more about this procedure as well as the Department of Gastroenterology, Hepatology, and Nutrition at Cleveland Clinic Children's, visit clevelandclinicchildrens.org/GI. That's clevelandclinicchildrens.org/GI. You can also call us at 216-444-5437. That's 216-444-5437.

And finally, please remember it's important for you and your family to continue to receive medical care and receive regular checkups and screenings. And rest assured here at the Cleveland Clinic, we're taking all of the necessary precautions to sterilize our facilities and protect our caregivers and patients. Dr. Freiberg, thanks so much for joining us here on Butts & Guts.

Dr. Ben Freiberg: Thanks for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.