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PubMed1987

Laxative consumption in chronic nonorganic constipation.

We looked at laxative consumption and its relationship to bowel habits, total gastrointestinal transit time (TGITT), and symptoms in patients with chronic nonorganic constipation. Of the patients, 87.9% used laxative, 30% habitually. Laxative intake increased with age, so that habitual consumption was more frequent in patients with long-standing (greater than 10 years) constipation. Although habitual laxative users had a consistent trend toward lower bowel frequency and prolonged TGITT, no relationship was found among intake and observed bowel frequency, TGITT, or large bowel segmental transit time. Although laxatives induced more satisfactory or less difficult evacuations, they also caused diarrhea and mucus in the stool. Laxative consumption did not bring about any detectable improvement in the abdominal or extraabdominal symptoms usually associated with constipation.

Adolescent↗
PubMed1996

Chronic idiopathic constipation: pathophysiology and treatment.

Chronic constipation is common in the general population, especially in women, in its idiopathic form. However, confusion still surrounds its definition, despite recent efforts to standardize it. Constipation can be divided in two large subgroups-normal transit and slow transit. The have different pathophysiological bases still not completely understood. Most patients respond to simple therapeutic measures aimed at correcting dietary fiber intake and lifestyle. Others, however, need more aggressive treatment, including laxatives, psychological therapy, and biofeedback. In a few patients with intractable constipation, surgery might be indicated to give relief.

Chronic Disease↗
PubMedDate not supplied

Factors responsible for persistence of childhood constipation.

In this study 56% of children with chronic constipation and encopresis were unable to defecate rectal balloons. Most of them had an abnormal contraction of the external and sphincter during defecation trials. Eighty-six percent were still unable to defecate balloons 1 year later after having complied with a conventional treatment program. Only 14% of patients unable to defecate balloons had recovered by 1 year, whereas 64% of patients able to had recovered (p less than 0.02). Only 13% of patients unable to relax the external sphincter had recovered by 1 year, whereas 70% of those able to do so had recovered (p less than 0.01). In addition, none of the patients with an abdominal fecal mass present during the initial examination independent of ability or inability to defecate balloons had recovered (p less than 0.001). This study shows that abnormal defecation dynamics and the severity of constipation are predictors for persistence of chronic constipation and encopresis.

Adolescent↗
PubMed1996

Treatment of intractable constipation in children: experience with cisapride.

To establish whether cisapride is beneficial in children with intractable constipation, an open trial was performed. Chronically constipated children who had failed at least 12 weeks of medical therapy received cisapride at a dose of 0.2 mg/kg/dose TID for 12 weeks. Children with pelvic floor dyssynergia were excluded. Patients were followed prospectively for at least 12 months. Thirty children were initially enrolled, and 27 (14 boys, 13 girls) completed the study. At the end of 12 weeks of cisapride treatment, there was a significant increase in the number of bowel movements per week (1.43 +/- 0.52 to 6.48 +/- 4.16; p < 0.05) and significant decreases in the number of accidents per day (2.86 +/- 2.71 to 0.52 +/- 1.23; p < 0.05) and doses of laxatives used per week (14.33 +/- 5.84 to 3.37 +/- 7.10; p < 0.05). Encopresis disappeared in 65.2% of cases (p < 0.0001) and improved in 26%. Sixty-nine percent of the patients stopped using laxatives (p < 0.001). After 12 weeks 18 patients (66.6%) were asymptomatic, seven (25.9%) showed some improvement in bowel movement frequency and number of accidents, and two (7.4%) showed no improvement. The cisapride was well tolerated. After long-term follow-up (20 +/- 9.8 months), 37% of patients had recovered (asymptomatic and off laxatives and cisapride) and 29.6% were still asymptomatic but were using laxatives or cisapride. There were no differences in baseline characteristics between recovered and nonrecovered patients. We conclude that cisapride is effective in the treatment of some children with intractable constipation without pelvic floor dyssynergia.

Anal Canal↗
PubMed2001

Colonic diversion for intractable constipation in children: colonic manometry helps guide clinical decisions.

BACKGROUND: Colonic manometry helps discriminate functional and behavioral causes for childhood constipation from colonic neuromuscular disease. METHODS: Of 375 colonic manometries performed for clinical indications, 12 could not be interpreted because of chronic colonic dilation. Based on colonic manometries that showed either no contractions or an absence of the gastrocolonic response or an absence of high-amplitude propagating contractions, the authors recommended diverting colostomies or ileostomies in 12 chronically constipated children (mean age, 4 years; range, 2-14 years, 5 boys). Before study, medical treatment was ineffective in all children. These children had persistently dilated colons with pathologic diagnoses of intestinal neuronal dysplasia (n = 4), hypoganglionosis (n = 2), hollow visceral myopathy (n = 1), and normal (n = 5). RESULTS: Six to 30 months after diversion, the authors restudied all the children. Eleven of 12 diverted colons were no longer dilated. In two patients, abnormal motility involving the entire colon was unchanged from the initial study, small bowel motility was abnormal, and we recommended no further surgery. In two cases, the colon remained abnormal but small bowel motility was normal, and we recommended subtotal colectomy and ileoproctostomy. In four cases, the left colon remained abnormal, but the right colon was normal, and we recommended reanastomosis after left hemicolectomy. In four cases, motility in the diverted colons was normal, including a gastrocolonic response and high-amplitude propagating contractions, and the authors recommended reanastomosis. Defecation problems resolved in 10 of 12 when followed up 5 to 30 months after treatment. CONCLUSION: These data suggest that in some cases of intractable childhood constipation associated with colonic distention, temporary diversion improved colonic motility. Colonic manometry may be used to predict which patients will benefit from resection or reanastomosis.

Adolescent↗
PubMed2004

Colostomy for treatment of functional constipation in children: a preliminary report.

OBJECTIVES: Surgery is indicated in very few children with intractable functional constipation. A number of operations have been described with unpredictable outcome and significant morbidity. The authors present a series of 10 children who underwent a Hartmann procedure with end colostomy formation. METHOD: Preoperative management, in addition to maximum conservative measures, included psychologic referral, rectal biopsy, transit studies, and contrast enemas. A standard Hartmann procedure was performed with on-table rectal washout, formation of a proximal sigmoid colostomy, limited anterior resection of hypertrophic proximal rectosigmoid, and oversewing of the rectal stump. RESULTS: The series includes 10 pediatric patients (4 female, 6 male), in whom constipation was first reported at a median age of 3 years (range, 2 months-7 years) and surgical referral was made at 8 years (range, 1-14 years). Surgery was performed at a median age of 9.5 years (range, 2-15 years), and the median postoperative stay was 5 days (range, 4-9 days). Complications occurred in four patients (transient mild rectal discharge in 2, stomal prolapse in 1, and an unrelated small bowel obstruction in 1 patient with an additional Mitrofanoff stoma). Median postoperative follow-up was 31 months (range, 9-56 months), and the children and parents were all completely satisfied with the stoma. CONCLUSION: Colostomy formation is a potential surgical option for severe functional constipation with low associated morbidity and high patient satisfaction.

Adolescent↗
PubMed2000

Laparoscopic antegrade continence enema in situ appendix procedure for refractory constipation and overflow fecal incontinence in children with spina bifida.

PURPOSE: The antegrade continence enema procedure allows patients with neurogenic bowel to administer large volume enemas through a right lower quadrant stoma to flush the colon every other day. This procedure results in freedom from refractory constipation and diapers required by unexpected episodes of overflow fecal incontinence. We present a simplified laparoscopic technique using in situ appendix. MATERIALS AND METHODS: A total of 6 male and 10 female children with a mean age of 12 years (range 4 to 21) and neurogenic bowel secondary to myelomeningocele underwent the antegrade continence enema in situ appendix procedure. The procedure was done with laparoscopic assistance, and associated with other bladder and bladder outlet reconstructive surgery in 5 patients. In 3 patients, a purely laparoscopic antegrade continence enema in situ appendix procedure was performed. The appendix and cecum were mobilized, and the tip of the appendix was anastomosed directly to the skin of the right lower quadrant through 1 of the 5 mm. lower quadrant port sites. The continence mechanism is simply a function of the appendix length and the mucosal coaptation of the appendiceal lumen. A 6Fr silicone Foley catheter is used to stent the mucocutaneous anastomosis. Concomitant procedures included ileocystoplasty, ileovesicostomy, sigmoidovesicostomy or ureterovesicostomy, and/or pubovaginal sling done through a low Pfannenstiel incision after laparoscopic mobilization of the appendix and cecum. RESULTS: The 3 patients treated with the laparoscopic antegrade continence enema procedure ate the day of surgery and were discharged home the next morning. Constipation and fecal incontinence resolved in all cases. All antegrade continence enema stomas were catheterized easily with a 6 or 8Fr feeding tube and were continent. Complications in the 8 laparoscopic and laparoscopic assisted cases included stomal stenosis requiring dilation in the office and obstructive volvulus associated with malrotation requiring segmental resection. Patient mothers in particular were gratified by this procedure at a mean followup of 11/2 years. CONCLUSIONS: The simplified antegrade continence enema in situ appendix procedure works well for refractory constipation and overflow fecal incontinence in children with neurogenic bowel secondary to spina bifida. Coaptation of the appendiceal lumen and use of small catheters allow for persistent continence without a formal surgically constructed valve mechanism. The combined antegrade continence enema and either ileovesicostomy or sigmoidovesicostomy continent urinary diversion procedures allow children to control bowel and bladder evacuation programs. A laparoscopic approach is reasonable particularly in cases requiring no other procedures.

Adolescent↗
PubMed1994

Constipation in children.

Chronic constipation with or without fecal soiling remains an important cause of childhood morbidity. A number of articles have appeared in the past year to advance our understanding of the pathophysiology, treatment, and long-term outcome of functional constipation and to give us a new treatment approach for intractable constipation in children. Hirschsprung's disease has been localized to chromosome 10. In addition, the number of children with preoperative enterocolitis of Hirschsprung's disease has decreased, most likely due to the availability of anorectal manometry and better staining methods of the rectal biopsies, which has resulted in earlier diagnosis. The mean age at diagnosis decreased to 2.6 months. Neuronal intestinal dysplasia does not appear to be a unique clinicopathologic entity.

Age Factors↗
PubMed2006

Gastroesophageal reflux disease, colic and constipation in infants with food allergy.

PURPOSE OF REVIEW: This review assesses the role of food allergy in the pathophysiology of gastroesophageal reflux disease, colic and constipation in infancy. RECENT FINDINGS: Frequent regurgitation, persistent crying and constipation are common clinical problems in infancy. A subgroup of infants with these conditions may respond to hypoallergenic diets, but only few randomized clinical trials have been conducted. Skin prick testing and food-specific antibody levels are usually not elevated in these infants, whereas atopy patch testing may diagnostic. The mechanisms by which cow's milk and other food allergens induce gastrointestinal motility disorders are not understood. Apart from cell-mediated reactions, non-immunological effects of food constituents on gastrointestinal motility and gut microbiota may be involved in the pathogenesis. In the absence of reliable diagnostic tests, dietary elimination and re-challenge are usually required to confirm food allergy. A trial of amino acid-based formula or an oligoantigenic maternal elimination diet may be indicated in infants who have failed conventional medical treatment. SUMMARY: Food allergy may contribute to gastroesophageal reflux disease, colic or constipation in infancy. Infants with these conditions often respond to hypoallergenic formula or a maternal elimination diet. Further research is needed to define the mechanisms and clinical markers of gastrointestinal food allergy in infancy.

Colic↗
PubMed2006

A dose determination study of polyethylene glycol 4000 in constipated children: factors influencing the maintenance dose.

OBJECTIVES: To determine the doses of polyethylene glycol (PEG) 4000 without additional salts allowing normal bowel habits in childhood functional constipation. METHODS: This multicenter noncomparative study allocated children to 4 groups: 6-12 months, 13 months-3 years, 4-7 years, and 8-15 years. Constipation was defined as <1 stool/d for more than 1 month in children aged 6-12 months and <3 stools/w for more than 3 months in older children. Children randomly received either a nominal or a double starting dose. Treatment scheduled for 3 months could be adapted. Data were collected daily by the parents and rated at each visit by the investigator. RESULTS: In the 96 children included, the median (interquartile) effective daily doses were by groups; 3.75 (2.50-5.00) g, 6.00 (4.00-7.43) g, 11.71 (7.00-16.00) g, and 16.00 (16.00-24.00) g, respectively, i.e., around 0.50 g/day/kg with a potential increment of the maintenance dose with higher initial dosages. More children had a final dosage identical to the initial one when started on the nominal dose (73%) than with the double one (42%, P < 0.003). More than 90% of children recovered normal bowel habits. Fecal soiling ceased in >60% of children with this symptom at enrolment. Fecal mass in the rectum and abdominal pain were markedly reduced and appetite improved. CONCLUSIONS: A daily dose of PEG 4000 around 0.50 g/day/kg in children aged 6 months to 15 years is effective in more than 90% of constipated children and 60% of those with fecal soiling.

Adolescent↗
PubMed2006

Evaluation and treatment of constipation in children: summary of updated recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

Constipation is a common pediatric problem. To assist health care professionals who care for children with constipation, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) previously published a clinical guideline based on an integration of medical evidence with expert opinion. To evaluate studies published since then, the NASPGHAN Constipation Guideline Committee performed a comprehensive and systematic review of the medical literature since 1997, to identify, review and rate the quality of new evidence. Based on this review, the recommendations of the original clinical guideline were reaffirmed with several modified according to the new evidence. Below is a summary of the evidence reviewed for this update. The complete revised guideline is available online in its entirety.

Animals↗
PubMed2006

The use of enteral naloxone to treat opioid-induced constipation in a pediatric intensive care unit.

OBJECTIVE: To describe the effects of enteral naloxone used to treat opioid-induced constipation in pediatric intensive care patients. DESIGN: Retrospective chart review. SETTING: Pediatric intensive care unit. PATIENTS: Twenty-three patients who received opioid therapy and enteral naloxone in our institution from January 2003 to February 2004 were compared with a randomly sampled control group matched for age, weight, sex, and length of stay who received opioids but had not received enteral naloxone. INTERVENTIONS: None. MEASUREMENTS: Daily stool output, daily opiate usage, nutrition, adjuvant laxative use, and side effects were assessed. RESULTS: Patients stayed an average of 5 days (range, 0-13 days) in the pediatric intensive care unit before enteral administration of naloxone was instituted and received it for an average of 9 consecutive days (range, 3-30 days). Mean stool output for study patients before administration of enteral naloxone was 0.14 +/- 0.38 stools per day, whereas after its initiation it was 1.60 +/- 1.14 stools per day (p < .001). However, two patients developed significant opiate withdrawal symptoms after receiving enteral naloxone. The average stool output for control patients was 0.53 +/- 1.21 stools per day. CONCLUSIONS: Enteral naloxone may be effective in increasing stool output in opioid-induced constipation but carries the risk of introducing withdrawal symptoms. Further studies are needed to evaluate this agent for opioid-induced constipation in the intensive care unit.

Adolescent↗
PubMed1994

Shunt dysfunction and constipation: could there be a link?

A ventriculoperitoneal (VP) shunt is the treatment of choice for hydrocephalus, functioning by means of a pressure differential between the ventricular system and peritoneal cavity. Constipation is frequently a concomitant problem in children with VP shunts. A case study is reported in which signs and symptoms of shunt dysfunction appear to have developed as a result of constipation. Nurses and physicians must address the need for preventing constipation much more aggressively in the population requiring shunts.

Child, Preschool↗
PubMed2005

Tegaserod is effective in the initial and retreatment of irritable bowel syndrome with constipation.

BACKGROUND: Symptoms of irritable bowel syndrome are often cyclical and thus may require repeated rather than continuous therapy. Tegaserod is effective and well-tolerated for irritable bowel syndrome with constipation but data on retreatment are lacking. AIM: To assess whether tegaserod retreatment is as efficacious and well-tolerated as initial treatment in a primary care setting. METHODS: This open-label trial was designed to evaluate the effectiveness of tegaserod under real-life conditions. Irritable bowel syndrome with constipation patients received tegaserod 6 mg b.d. for 12 weeks; response was assessed at weeks 4 and 12. Responders (those achieving satisfactory relief for at least 2 of the previous 4 weeks) at weeks 4 and/or 12 entered an 8-week withdrawal period where symptom recurrence was assessed. Patients experiencing recurrence could receive tegaserod 6 mg b.d. for another 4 weeks (retreatment phase) and on completion, could choose to continue tegaserod in a 6-month extension study. RESULTS: A total of 513 patients received initial treatment with tegaserod; 85.0% (436 of 513) responded. 403 responders entered the withdrawal period; symptoms recurred in 83.9% (338 of 403) after a mean of 38 days. Of the 307 patients who subsequently entered retreatment 89.3% (274 of 307) responded. Among patients entering the retreatment period, 269 (87.6%) had responded within the first 4 weeks of initial treatment. Of these, 243 (90.3%) responded to tegaserod retreatment. Adverse events were infrequent and similar during 4 weeks of the initial treatment period (11.1%) and on retreatment (10.4%). The extension study, completed by 188 of 232 (81.0%) patients, demonstrated good long-term tolerability of tegaserod. CONCLUSIONS: Irritable bowel syndrome with constipation patients can be successfully treated, and retreated, with tegaserod 6 mg b.d. Tegaserod was well-tolerated during initial and retreatment periods.

Adolescent↗
PubMed2005

The effect of fluoxetine in patients with pain and constipation-predominant irritable bowel syndrome: a double-blind randomized-controlled study.

BACKGROUND: Irritable bowel syndrome has been treated with selective serotonin reuptake inhibitors but there is not enough evidence from controlled trials to prove their effectiveness. AIM: To compare the effects of fluoxetine and placebo in the treatment of pain and constipation-predominant irritable bowel syndrome in a double-blind randomized-controlled trial. METHODS: Forty-four cases meeting Rome II criteria for irritable bowel syndrome with predominance of pain and constipation were included in this study. Organic causes were ruled out by detailed history, physical examination, laboratory tests and colonoscopy. Participants were then randomly assigned to receive either fluoxetine or placebo for 12 weeks. Symptoms addressed by the Rome II criteria were recorded during treatment and 4 weeks after termination of treatment. RESULTS: Fluoxetine was significantly more effective than placebo in decreasing abdominal discomfort, relieving feeling and sense of bloating, increasing frequency of bowel movements and decreasing consistency of stool. Mean number of symptoms per patient decreased from 4.6 to 0.7 in the fluoxetine group vs. 4.5 to 2.9 in controls (P < 0.001). CONCLUSIONS: Fluoxetine is an effective and well-tolerated short-term treatment for pain and constipation-predominant irritable bowel syndrome.

Abdominal Pain↗
PubMed2005

Outlet type constipation in Parkinson's disease: results of botulinum toxin treatment.

BACKGROUND: Constipation is one of the most common autonomic dysfunctions observed in Parkinson's disease. AIM: To investigate the efficacy of injections of botulinum toxin in improving rectal emptying in these patients. METHODS: Eighteen Parkinson's disease patients with outlet constipation were included in the study. The patients were treated with type A botulinum toxin, injected into two sites on either side of the puborectalis muscle under ultrasonographic guidance. RESULTS: Symptomatic improvement was noted in 10 patients, at 2 months evaluation. In these subjects, anorectal manometry demonstrated decreased tone during straining from 96.2 +/- 17.1 to 45.9 +/- 16.2 mmHg at 1 month evaluation (P = 0.00001) and to 56.1 +/- 10.7 mmHg at 2 months (P = 0.00001). Pressure during straining was lower than resting anal pressure at the same times in all patients. Defecography after the treatment showed improvement in anorectal angle during straining, which increased from 99.1 +/- 8.4 degrees to 121.7 +/- 12.7 degrees (P = 0.00001) at 2 months. CONCLUSIONS: Botulinum toxin injections may be a useful treatment for Parkinson's disease patients affected by outlet-obstruction constipation. The treatment is safe and simple. However, because the effects of the toxin wear off within 3 months of administration, repeated injections could be necessary to maintain the clinical improvement.

Aged↗
PubMed2006

Effect of a laxative with and without tegaserod in adolescents with constipation predominant irritable bowel syndrome.

AIM: To determine the effect of a laxative alone and in combination with tegaserod in alleviating pain and improving stool frequency in adolescents with constipation predominant irritable bowel syndrome. PATIENTS: Forty-eight postpubertal adolescents of both sexes with constipation predominant irritable bowel syndrome, as defined by Rome II criteria, were randomly allocated to Group A (n = 27) for treatment with a laxative (polyethylene glycol 3350 oral solution) only or Group B (n = 21) for combination therapy with the laxative and tegaserod. Symptoms of abdominal pain (scale 0-10) and frequency of bowel movements were recorded daily in the pre-treatment phase and the post-treatment phase after a 7-day 'washout' period. Patients served as their own controls. RESULTS: Treatment with the laxative alone (Group A) resulted in significant increase in frequency of bowel movements (P < 0.05), but not significant improvement in pain (P > 0.05). Treatment with the combination of the laxative and tegaserod (Group B) led to significant increase in the frequency of bowel movements and also significant reduction in pain (P < 0.05). CONCLUSIONS: The laxative alone improved stooling but not pain in adolescents with constipation predominant irritable bowel syndrome. Addition of tegaserod resulted in alleviation of pain as well.

Abdominal Pain↗
PubMed2005

Effect of MKC-733, a 5-HT receptor partial agonist, on bowel motility and symptoms in subjects with constipation: an exploratory study.

BACKGROUND: MKC-733, a 5-HT(3) receptor partial agonist, is a novel enteroprokinetic compound. OBJECTIVE: The aim of this study was to explore the effects of MKC-733 on bowel motility and symptoms in a small group of subjects with constipation. Tolerability was also examined. METHODS: The study was conducted in a single-blind and dose-escalation manner on 14 male and female subjects with constipation aged 22-67 years. After a 1 week run-in period, subjects were treated with placebo (b.i.d.) for 1 week, and 0.2 and 0.5 mg of MKC-733 (b.i.d.) for 2 weeks sequentially. Geometric mean and per cent elimination of surrogate markers of bowel motility were measured by a radio-opaque marker technique at the end of each treatment period. They were analysed on the whole group and subgroups with low (n = 6) and high (n = 8) bowel motility based upon the geometric mean value after placebo treatment. Subjects kept diaries of their bowel habits and gastrointestinal symptoms. RESULTS: Percent elimination increased after treatment with 0.5 mg MKC-733 compared with placebo treatment in the whole group (70.4 +/- 33.5% vs. 47.1 +/- 36.6%, mean +/- SD, P < 0.05). In the low bowel motility group, both geometric mean and percent elimination increased after treatment with 0.5 mg MKC-733 compared with placebo (7.1 +/- 0.9 vs. 5.9 +/- 0.5, P < 0.05; 60.0 +/- 35.8% vs. 13.3 +/- 19.4%, P < 0.05). Stool frequency increased after the first-week treatment with MKC-733 compared with placebo (P < 0.05). Numbers of sensation of incomplete evacuation and gastrointestinal symptoms decreased to half and less after the treatment with MKC-733. No serious adverse effect was noted. CONCLUSION: Multiple doses of 0.5 mg MKC-733 improve bowel motility, which was clearly demonstrated in the subjects with decreased bowel motility. MKC-733 at the doses studied might be effective in increasing stool frequency and reduce gastrointestinal symptoms related to constipation. MKC-733 was well tolerated. Further studies will be needed to clarify efficacy and safety of MKC-733 on a larger population.

Adult↗