Anal prolapse is getting more frequenct since beginning of the therapy with Kreon

Question

Our son has digestional problems for a longer time and got about 5 weeks ago for the first time an anal prolapse. The tests that had been done then revealed that he suffers from CF and the anal prolapse is therefore regarded to be cause by the illness of CF. After the first prolapse, it lasted 9 days after another prolapse occurred. After this, it reoccurred after 7 days.
For 3 weeks, our son takes Kreon with his meals. The first reaction was a stool pause for 3 days and since the first stool, that he got after this pause, he has again several times stool a day. Unfortunately, each of these stools is accompanied with an anal prolapse and this even enlarges compared to the first ones and regresses more and more difficult and more slowly. On the one hand this is accompanied with pain for our 3-year-old son, on the other hand we had once to go to the CF Center where a pediatric surgeon had to replace the prolapse. One cannot talk about a spontaneous regression anymore.
Can these freuqent prolapses could have something to do with an intolerance of Kreon? In order to keep the stool soft, the CF Center prescribed today Makrogol, which we should give for 3 weeks twice a day. Is this a solution, to soften the stool and at the same time give Kreon? I am worried, to do it like this and to experience several times daily an anal prolapse, that is regressing more and more difficult spontaneously.
Many thanks for your answer!

Answer

Hello,
you report, that your 3-year-old son experienced about 7 weeks ago for the first time an anal prolapse and that as a conseuquence the performed diagnostics revealed the illness of CF in your son. After starting the therapy with Kreon, there had been a stool pause of 3 days. After this pause, your son got again several times a day stools and in the meantime anal prolapses occurred more frequently, whereby the prolapses turned bigger and do not regress spontaneously anymore.
You ask, if the now more frequently occurring anal prolapses could be a sing of an intolerance of Kreon. From your CF Center, a therapy with Macrogol has been proposed, in order to soften the stool. You ask, if this approach is sensitive, as your are afraid of more freuqent anal prolapses.
It is difficult to make a recommendation without knowing further details and results of your son.
In general it can be said, that it cannot be expected, that in case of a 3-year-old child with CF, who already had several anal prolapses, those prolapses stop immediatley after beginning a therapy with Kreon. Prolapses occur indeed in case of CF patients via a long-term mechanical tensile loading of the gut walls in the rectum due to discharge of viscous and sticky fatty stools. Via a therapy with Kreon, the stool consistency changes and the tensile loading gets less. In case of your son, he had immediately a stool pause after beginning of the therapy. For the prolapses that occurred in the meantime, different factors could play a role. At first it has to be asked if the Kreon dosage is right. (Guidelines: 2.000 to 3.000 units per gram nutritional fat - maximum dosage not more than 10.000 IU per Kg body weight). In order to check the correct dosage, a stool fat investigation is probably necessary. If in spite of a correct dosage there is increased stool fat, the way of drug intake has to be checked and if this is correct, a nutritional protocol has to reveal the fat content of the daily food and probably if it has to be lowered.
If in spite of a normal fat intake and optimal dosing of enzymes the stool fat excretion should be too high, an accompanying therapy with a so-called proton-pump inhibitor should be done in order to elevate the ph value in the small bowel and to achieve by this a more optimal effect of Kreon.
It is of course also possible, that an instantly occurence of a gut infection came together with the starting of the Kreon therapy and that by this, he had an increased stool frequency, that had an ongoing burden of the rectal system as a conseuqence in your son. If the above mentioned factors have been checked, also a kind of intolerance of Kreon has to be taken into account. This is very rare. It should then be tried, to change the preparation and to see if it brings a relief.
Besides the pancreatic insufficiency in case of CF, another reason for an anal prolapse in children is a longer lasting diarrhea. Therefore, the frequent stools can cause such a high mechanical burden of the rectum even without pancreatic insufficiency, that a prolapse occurs.
For this reason, I would rather dehort the proposed therapy with Macrogol, as this will with high probability increase the stool frequency. Concerning nutrition, it should be paid attention to an age-adapted and stool softening nutrition, that is characterized by a high proportion of fruit and a balanced but not too high content of fibers.
Because of the frequent prolapses it came to a swelling of the rectal mucosa of your child. This is giving your son the impression, that the rectum is filled and therefore that he has to release stool. You have to try to keep your son away from following this feeling too often, as via every “unnecessary” pressing, the risk of getting a prolapse increases. It is difficult to make this clear to a 3-year-old child.
In the end, one should expect a success of the therapy of the anal prolapse in case of optimal dosage of enzymes and therefore a normal stool consistency and normal frequency (1-2 stools per day). Unfortunately this needs sometimes much patience from the people involved.
We wish you and your child a fast relief of this problem.
Dr. H.-G. Posselt

16.07.2016