This paper from the APSA Hirschsprung disease Interest Group [1] shows very well the current protocols for investigation and treatment of soiling in children after surgery for Hirschsprung disease (HD). The authors classify the causes into three main categories: sensory deficiency, abnormal sphincter control and ‘pseudo-incontinence.’

In many patients, the ‘pseudo-incontinence’ is associated with hypermobility, with rapid transit through the remaining colon. This so-called rapid-transit constipation (RTC) can be documented on contrast enema or transit study, and sometimes manometry, and often responds to anti-motility agents, such as Loperamide. Our group has been researching the causes of RTC recently, and in both HD and otherwise normal children with RTC, breath tests have identified malabsorption of one or more of the ‘FODMAP’ sugars. We have now treated many children with positive breath tests with exclusion diets, eliminating the specific sugar(s), with a marked improvement in their symptoms [1,2,3].

We think that many children with ‘pseudo-incontinence’ may have hypermobility secondary to irritable bowel syndrome (IBS), and may benefit from specific diagnosis by breath tests, and then precise dietary exclusion. We would like to draw the attention of the HD interest group to these potentially exciting results [2,3,4].