Spastic left colon syndrome after long-term, high-volume antegrade continence enema use: a case series

Introduction Spastic left colon syndrome is a recently described complication of chronic antegrade continence enema (ACE) therapy characterized by flush-related symptoms and contrast enema findings of a dilated proximal colon with a spastic left colon. Management strategies have not been previously described. Case Presentations Four adolescents with spastic left colon syndrome were treated between 2018 and 2023. A 16-year-old female with Hirschsprung disease developed urgency, watery stools, bloating, and incomplete evacuation after 10 years of ACE therapy. She successfully transitioned off enemas to senna and remained symptom-free at 2-year follow-up. A 16-year-old male with anorectal malformation developed worsening fecal incontinence after 3 years of ACE use. Reduced flush frequency and loperamide allowed eventual discontinuation of enemas and medications, with sustained symptom resolution at 2 years. A 16-year-old male with anorectal malformation developed urgency, frequent small-volume stools, and activity-related symptoms after 5 years of ACE therapy. Senna alone was unsuccessful; gradual reduction of flush volume combined with intermittent loperamide resulted in predictable bowel function without urgency or accidents at 6-month follow-up. An 18-year-old female with spina bifida developed prolonged evacuation times and fecal incontinence after 8 years of ACE therapy. Hyoscyamine before flushes and intermittent bisacodyl improved continence and evacuation efficiency. All patients required close follow-up because minor regimen adjustments produced substantial symptom changes. Conclusion Decreasing flush volume and frequency with the addition of medication to slow colonic motility appears to be most helpful in strategy for the management of children with spastic left colon syndrome.