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This article presents a diagnostic and therapeutic approach to children with constipation. Causes of constipation can be organic or non-organic (functional). Functional constipation may lead to functional fecal retention. The history and physical examination are most important. Laboratory and radiologic examinations are not warranted in the majority of children.
BACKGROUND/AIMS: A recent study has demonstrated that rectal balloon distension effected inhibition of jejunal and ileal motility (Shafik, Hepatogastroenterology, 2000). It was hypothesized that rectal distension occurring in rectal inertia constipation might cause enteric hypotonia. This hypothesis was investigated. METHODOLOGY: Twenty-three patients with rectal inertia constipation (18 women, 5 men mean age 38.8 +/- 10.6 SD years) and 10 healthy volunteers (7 women, 3 men, mean age 37.2 +/- 9.8 SD years) were studied. The rectal, jejunal and ileal pressures were measured by means of saline-perfused tubes. The pressure response of rectum, jejunum and ileum to rectal balloon distension in increments of 50 mL of saline was recorded. RESULTS: The mean basal rectal, jejunal and ileal pressures measured in the patients with rectal inertia were significantly (P < 0.05) lower than those of the volunteers. Fifty-milliliter rectal balloon distension caused no rectal, jejunal or ileal pressure response in either the volunteers or patients. One hundred-milliliter distension effected in volunteers a rectal pressure elevation (P < 0.001) and a decline of jejunal (P < 0.05) and ileal (P < 0.05) pressures which were maintained as long as rectal distension was continued. In patients, no significant (P > 0.05) pressure changes were registered from the rectum, jejunum or ileum. Rectal distension with 150 and 200 mL caused balloon expulsion in the volunteers and in patients no significant rectal, jejunal or ileal pressure changes (P > 0.05). CONCLUSIONS: Rectal inertia was associated with reduced jejunal and ileal pressures, presumably indicating the presence of enteric hypotonia. The inertia-hypotonia relationship is proposed to be mediated through the recto-enteric reflex and transmitted by the enteric nervous plexus. The enteric hypotonia is suggested to prolong the intestinal transit, act as a contributing factor in the genesis of constipation and may explain some of its clinical manifestations.
OBJECTIVE: To investigate the pathogenesis, the diagnostic criteria, and the therapeutic method of idiopathic slow transit constipation. METHODS: History recording, bowel transit, anorectal dynamic, electromyography of the pelvic floor and defecography were performed before subtotal or total colectomy for severe constipation resistant to conservative treatment. RESULTS: The natural stool frequency was decreased and the time of bowel transit was delayed. The rectal sensation and the ability to reflect inhibition of the pelvic floor when attempting to defecate were damaged significantly compared with normal controls. pathological findings showed that the argyrophilic neurons in the myentenic and submucous plexus reduced quantitatively. All the patients were followed up for an average of 32.2 months. Satisfactory functional outcome was obtained in 91.8% of the patients receiving the operation. CONCLUSIONS: The severe damage colon transit function is due to the impairement of the myentenic and submucous plexus of the colon. It causes vary. The diagnosis of the disease is dependent on the typical clinic features and the bowel transit test. The symptoms of constipation could be relieved effectively by removal of the pathologic colon.
Severe chronic constipation is defined as less than two bowel movements per week, hard stools, non productive urgency and the need of digital maneuvers in more than 25% of bowel evacuations. The best studied causes of chronic severe constipation are slow bowel transit constipation and pelvic floor dysfunction. However, there are mixed forms that cross link with irritable colon syndrome. The main diagnostic tests are anorrectal manometry, bowel evacuation, X-ray studies and anorrectal sphincteromyomectomy, that can be therapeutic. Five percent of patients are surgical candidates. In cases of slow bowel movement, total colectomy with ileorectal anastomosis has satisfactory results in 80 to 90% of patients. Some patients with pelvic floor dysfunction have an occult rectal prolapse, rectocele or sigmoidocele and obtain benefits with the correction of these conditions. The remaining patients require a training of bowel evacuation, known as biofeedback. We have performed a total colectomy in 10 patients with slow bowel movements with good functional results in 80%. After 56 months of follow-up, a mean 2.6 bowel movements per day is reported by the patients. Four patients were also operated due to a solitary rectal ulcer and two patients due to a sigmoidocele, with satisfactory results.
OBJECTIVE: To determine the efficacy and safety of tegaserod 6 mg b.i.d. in the treatment of constipation-predominant irritable bowel syndrome (C-IBS). METHODS: An 8-week, double-blind, randomized, parallel group, placebo-controlled, multicenter study in 510 Chinese patients who met the Rome II criteria for C-IBS. The study consisted of a 2-week baseline period, a 4-week randomized, double-blind treatment period with either tegaserod 6 mg b.i.d. or placebo (tegaserod:placebo = 1:1), followed by a 2-week withdraw period. Efficacy was assessed by patient's perception of overall symptoms of IBS during the previous week and severity of the patient's constipation during the last week and patient's assessment of their individual IBS symptoms. Safety was assessed by adverse events, laboratory evaluations, blood pressure and heart rates, Physical examination and ECG evaluations. RESULTS: The weekly severity of patients' perception of overall IBS symptoms was significantly lower in the tegaserod group from week 1 onwards and throughout the treatment period. The effects of tegaserod on secondary IBS efficacy parameters were consistently better in the tegaserod group starting in week 1 and lasting throughout the treatment period and withdraw period. Regarding adverse events during the treatment period, about 10% of the patients in the tegaserod group experienced an adverse event compared to 6% in the placebo group. Diarrhea, abdominal pain and dizziness were more frequent in the tegaserod group but had a low frequency. No serious adverse was observed due to tegaserod. CONCLUSIONS: Tegaserod 6 mg b.i.d. was effective in relieving overall IBS symptoms, constipation, abdominal discomfort and pain, bloating, etc with significant effects starting in week 1 and continuing throughout the treatment period. Tegaserod was generally well-tolerated and has no clinically relevant safety findings.
The childhood prevalences of constipation and encopresis are 0.3-8% and 1-3% respectively. Following a recent stricter definition and classification, constipation and solitary encopresis are now recognised to be two separate entities. Constipation is characterised by infrequent defecation, often in combination with involuntary loss of faeces. Solitary encopresis most often occurs once a day after school hours. When there is no defecation, the frequency of encopresis increases, the abdominal pain becomes more severe and the appetite becomes less, until a large quantity of faeces is produced (often once per week). The physiology of the defecation and continence mechanism is complex and has only been unravelled in part. The multiple physiological mechanisms involved have a complementary and compensatory effect on each other. This makes it difficult to determine the underlying pathophysiological mechanisms of these functional disorders.
A large number of children suffer habitually from constipation, a problem which bears considerable repercussions on the physical and emotional well-being of the patient and causes tensions in their family environment. From 1996 to 1999, the authors studied the clinical and epidemiological data from patients in a Primary Health Care Pediatrics. Ward at which the main reason for consultation, or at least one of the main reasons, was chronic constipation. In this article, the authors evaluate the clinical and epidemiological characteristics of 68 children whose ages vary from 3 to 13 out of a total of 1368 who were diagnosed with functional constipation as well as the results obtained from a plan to assess, care for and treat these patients.
In 32 female patients with severe constipation subtotal (n = 27) or partial (n = 5) colectomy was performed. In 8 cases slow transit constipation was preexistent, 24 patients had a megacolon/dolichocolon. Ileosigmoid anastomosis was found to show the most favourable results. None of these patients complained of constipation postoperatively and all of them reported regular (daily) bowel movements. Incontinence for flatus and/or liquid stools was less likely to occur with ileosigmoid than with rectal anastomosis (29 versus 46%).
OBJECTIVE: To review paediatric admissions with a primary diagnosis of constipation to see whether some could have been managed in the community instead. METHOD: A review of the medical notes of all patients admitted with a primary diagnosis of constipation to the children's ward of a district general hospital over a 12-month period. RESULTS: Of 41 admissions (19 girls and 22 boys, age range 6 weeks to 12 years), the average length of stay was less than two nights. CONCLUSION: The short duration of hospital stay implies rapid improvement. It is likely that many of these children could have been managed in the community if suitable resources, such as a community nurse specialising in constipation, were available.
Irritable bowel syndrome, constipation, and diarrhea may complicate a pregnancy. Complaints of IBS and constipation may be managed by nonpharmaceutical methods. A careful history should be conducted to determine whether these complaints are of an acute or a long-standing nature. Conservative treatment of IBS is recommended and may include stool-bulking agents, a high-fiber diet, elimination of offensive foods, and the behavioral treatment of passive muscle relaxation, biofeedback or supportive psychotherapy. Constipation is generally self-limiting. It also may be treated conservatively with stool-bulking agents, increases in dietary fiber, and the addition of pelvic muscle exercises, preferably using electromyographic biofeedback. Laxatives should be used judiciously (Table 1). Diarrhea is caused most often by infectious agents in pregnancy but may also be from food poisoning or a viral disease. Infectious diarrhea may be treated by mild antidiarrheal agents and safe antibiotics. Fluid replacement is the mainstay of treatment, and care should be taken, remembering that the treatment involves two patients. These complaints can generally be managed conservatively, but persistent cases should be investigated as in a nonpregnant patient.
BACKGROUND AND AIMS: Besides incontinence, constipation is important after TAR. We aimed at evaluating their correlation and role in functional outcome. MATERIALS AND METHODS: 81 diaries in 16 patients (up to 8 years) were assessed, by a specific scoring system, regarding incontinence and evacuation. In the overall series and in three postoperative time groups, the correlation between the two items, their mean scores and relative score rates (% of the maximum possible scoring) were calculated. RESULTS: The Spearman correlation coefficient in all assessments was -0.128. According to timing, it was: 0.468 (short term), -0.036 (mean term) and -0.69 (long term). Incontinence was more disabling than evacuation; constipation occurred more frequently. Incontinence improved over time; constipation did not substantially change. CONCLUSIONS: Current criteria for functional assessment do not describe the true conditions after TAR and their variations over time. Profound consideration is necessary before announcing ultimate judgements on TAR.
Various agents are used for the medical management of chronic constipation but few have been carefully studied. This review examines available data concerning several bulk and fiber products, lubricating agents, stimulants, and osmotic laxatives, alone and in combination. Popular therapeutic options for initial treatment of chronic constipation are dietary fiber and medicinal bulk. Subsequent treatments if fiber is not successful or tolerated would include saline osmotic laxatives, lactulose, or stimulants like senna or bisacodyl. Recent data demonstrate polyethylene glycol laxative to be safe and effective as an initial or second-line agent for chronic constipation. Indications and use of surgery and biofeedback are also discussed.
Colonic massage has been claimed to be an efficacious treatment for chronic constipation, though there are no studies to prove this. We therefore investigated the effect of abdominal wall massage on stool frequency and colonic transit time of radiopaque markers in 9 constipated patients (68 +/- 5 years, 5 female, colonic transit greater than 60 h) and in 7 healthy male volunteers (27 +/- 1.2 years) in a control phase and during a three week treatment phase with 9 sessions. Massage was performed as propulsive abdominal wall massage along the presumed course of the colon in an aboral direction (each session 20 min). Stool frequency did not change significantly from control to massage, neither in patients [0.59 +/- 0.08 to 0.68 +/- 0.09 defaecations per day, 95% CI control-massage (-0.23; 0.04)] nor in healthy volunteers 1.11 +/- 0.11 to 0.86 +/- 0.13, 95% CI (-0.01; 0.53)]. Total colonic transit times remained similar during the control and massage phase in patients (126 +/- 19 and 111 +/- 17 h, 95% CI (-11; 41)] and in healthy volunteers (40 +/- 7 and 38 +/- 6 h, 95% CI (-8; 13)]. Even when patients and healthy volunteers were statistically evaluated together, control and massage did not differ significantly. In patients, scores of well-being and stool consistency did not differ significantly during control and massage periods. So colonic massage does not change parameters of colonic function to a clinically relevant degree in healthy volunteers and constipated patients of the investigated age-groups.
The genesis of chronic constipation in children remains the subject of discussion so far. A programme for examining patients with this condition has not been fully developed. X-ray studies of more than 300 children with chronic constipation from different age groups established that colonoproctodefecography was the most informative technique. The authors revealed that intestinal transit suffered slightly impaired and the cause of chronic constipation was impaired defecation due to the asynergy of the structures of the pelvic bottom. Dysfunction of the muscular structures of the pelvic diaphragm manifested itself as three main variants and their combinations.
Constipation is a common and debilitating symptom in patients with advanced cancer. If ignored, constipation will get worse. If left untreated, it can greatly reduce a patient's quality of life. An improved understanding of bowel function and knowledge of the recognised risk factors will lead to a greater appreciation of the signs and symptoms of constipation.
Constipation is a common condition in developed and industrialised nations. Although its exact prevalence is unknown it is estimated that between five and thirty per cent of the U.K. population suffer with it, depending on the criteria used for diagnosis (Candelli, 2001). Constipation that cannot be explained by any underlying abnormalities is known as idiopathic constipation.
OBJECTIVE: To summarize the causes and treatment experiences of postoperative constipation recurrences of Hirschsprung disease. METHODS: Clinical data of 37 cases receiving operation again for postoperative constipation recurrences of Hirschsprung disease were collected. The recurrent causes, reoperation procedures and therapeutic efficacy were analyzed. RESULTS: Among 37 cases, the recurrent causes included insufficient resection of the intestine in 14 cases, co-existent intestinal neural hypogenesis in 6, gate syndrome in 5, and others in 12 cases. There was no postoperative death. Thirty-one cases (83.8%) were followed-up from 6 months to 11 years. The defecation frequency was 1-2 times per day in 15 cases, one times per two days in 7, one times per three days in 6 cases. Two cases could defecate with the help of laxative purgatives. Nobody had incontinence. CONCLUSION: The main cause of postoperative constipation recurrences of Hirschsprung disease is insufficient resection of the intestine,and reoperation can get better results.
Constipation is a highly prevalent and bothersome disorder that negatively affects patients' social and professional lives and imposes a heavy economic burden on patients and society. Most patients with chronic constipation are evaluated and treated in the primary care setting. Primary care clinicians often underestimate how much they can accomplish in the evaluation of a patient with constipation before they make a referral. There are numerous steps that primary care clinicians can take to address these issues and maximize the benefits of the referral process, including understanding key elements of an effective diagnostic work-up, familiarizing themselves with the utility of various diagnostic tests of colonic and anorectal function, implementing strategies/instruments to optimally communicate what they are striving to achieve through the referral process (eg, via a referral form), and developing a network of long-term working relationships with local gastroenterologists.