Severe Pediatric Constipation Treatment & Management

Updated: Nov 29, 2017
  • Author: Marc A Levitt, MD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
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Treatment

Nonoperative Therapy for Postoperative Constipation and Diarrhea

Recognizing the different types of fecal incontinence is vital in the treatment of a patient with fecal incontinence after surgery for anorectal malformations or Hirschsprung disease. The clinician must learn how to evaluate these patients, how to recognize the specific type of fecal incontinence, and how to implement the best treatment modality. In addition, the clinician must confirm that the patient has achieved the best possible anatomy (eg, a properly located anoplasty or an unobstructed Hirschsprung pull-through) before starting any treatment to improve function.

If true anatomically based fecal incontinence is determined to be present, the first step is teaching the family and patient how to clean the colon with an enema. In patients with slow motility, this is a challenge. The correct enema type and amount needed to clean the colon must be determined. Keeping the colon quiet for 24 hours until the next enema is not difficult, because the patient has slow motility.

In patients with fast motility, cleaning the colon with an enema is easy. The challenge in these patients is to keep the colon quiet for 24 hours until the next enema. Controlling the hypermotility requires a constipating diet and medications such as loperamide and water-soluble fiber.

These patients must be seen regularly. The treatment process is one of trial and error, and the vast majority of patients can have initial success with the bowel management program within 1 week. The process of finding the correct medical regimen for the hypermotility group can be challenging and may take longer than 1 week. Careful long-term follow-up is needed to maintain this success.

The problem of overflow pseudoincontinence must be suspected in the evaluation of a patient born with a benign anorectal malformation, which is associated with a good functional result. These patients often experience severe constipation that has not been properly treated and present with what the family believes is fecal incontinence.

Such a patient must first be disimpacted. Then, over several days, bowel control must be determined. If the patient is truly incontinent and constipated, bowel management with enemas is necessary. On the other hand, if the patient has bowel control, they need a determined dose of laxative given on a permanent basis with an option for a sigmoid resection, which may make management easier by significantly decreasing the laxative requirements.

Constipation in patients with incontinence

Patients with constipation (ie, slow motility) are much easier to treat than those with diarrhea. The rectum normally remains quiet for 24-48 hours, after which the rectosigmoid contracts and empties during a normal episode of defecation. The rectosigmoid then remains quiet for 1-2 days.

To manage constipation, daily cleaning of the colon with an enema is used. If the rectosigmoid has been preserved, as is the case with a posterior sagittal anorectoplasty (see Imperforate Anus, Surgical Perspective), the patient often experiences varying degrees of constipation and the inability to empty the colon completely in a single bowel movement. These patients require large enemas and no specific dietary restrictions or medications.

The child sits on the toilet for 30-45 minutes, usually in the evening. Saline enemas are used with the addition of glycerin or soap (which are colonic stimulants). An enema that is correctly administered on a daily basis should result in a bowel movement followed by a period of 24 hours of complete cleanliness.

The volume of the enema is determined by trial and error. A No. 20-24 Foley catheter is lubricated and gently introduced through the anus (see the images below). The Foley balloon is inflated to act as a plug.

Enema administration with a tube. Enema administration with a tube.
Enema with inflated Foley balloon catheter. Enema with inflated Foley balloon catheter.

If the child soils at any point during the following 24 hours, the bowel washout was likely incomplete, and a more aggressive enema is required. The volume of saline can be increased, or more additives can be used. Sometimes an enema is too strong and causes the accident. An abdominal radiograph helps determine which of these was the cause of the event. The program is individualized, and parents and children learn to examine the consistency and amount of stool obtained after the enema to determine whether it was effective.

Diarrhea in patients with incontinence

If the rectosigmoid was resected, as it would have been in an abdominoperineal procedure or an endorectal dissection (a procedure some surgeons in the past used to repair imperforate anus), the patient has loose stool (ie, fast motility) as a consequence of the loss of the section of the colon most responsible for water absorption, and thus continuously passes stool. These patients are also very sensitive to foods that provoke liquid stools.

Liquid stool is problematic in children with anorectal malformations. This type of stool does not distend the rectum and leaks out without the child’s knowledge. The goal of instituting bowel management in these patients is to have them form solid stool so that they are able to feel something with distention of the rectum and to use their voluntary muscles in time.

Rapid transit of stool results in frequent episodes of diarrhea. Stool passes so rapidly from the cecum to the descending colon that these patients are unable to remain clean, even after administration of an enema. The bowel management program consists of teaching parents and patients a method of cleaning the colon completely every day and simultaneously determining a method to keep the colon quiet for 24 hours.

To decrease diarrhea, constipating diets and medications (eg, loperamide) and water-soluble fiber are used to slow down the colon. A small daily enema is required. Keeping the colon clean is relatively easy; keeping it quiet between enemas is difficult.

Incontinence vs overflow pseudoincontinence

Distinguishing between fecal continence and fecal incontinence is vital. Many patients present with severe constipation but are fecally continent. They may demonstrate signs of overflow pseudoincontinence if their colon is filled with stool and if they are impacted. Constipation management with laxatives can solve this problem.

Patients who are incontinent and have constipation are very different. No matter how great the amount of laxatives administered, they cannot empty their colon with any control. These patients require daily enemas (ie, a mechanical program) to clean the colon completely.

Making this distinction is sometimes difficult. Occasionally, patients present with incontinence and severe constipation. Once the impaction is managed, they are continent if constipation is avoided by use of laxatives.

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Nonoperative Therapy for Functional (Idiopathic) Constipation

Measures for mild constipation

In patients with mild forms of constipation, pediatricians and pediatric gastroenterologists use dietary measures. If this is not sufficient, stool softeners are administered. If stool softeners are not effective, stimulant laxatives are administered. Many such patients are referred, sometimes unnecessarily, to psychologists and subjected to behavior modification and biofeedback treatment. We have found that such patients can also benefit from bowel management techniques.

Trial of medical management

The protocol of treatment in patients with severe forms of functional constipation includes a trial of medical management (stimulant laxatives). If patients do not respond to this treatment, then a specific type of operation may be needed.

Almost always, the patient previously received less laxative than was required. The dosage is adjusted daily, and abdominal films are obtained every day to objectively evaluate the degree of fecal impaction until the correct amount of laxatives is determined.

In a study involving children with refractory idiopathic constipation, it was found that a structured bowel management program, based on assessment of clinical response and daily radiographs in a pediatric colorectal center with longitudinal follow-up, was effective and led to a dramatic reduction in hospital admissions. [9]

Disimpaction

When patients come for consultation, they are usually impacted. Treatment includes the administration of three enemas per day to disimpact (see the images below) or, sometimes, a bowel preparation with a balanced electrolyte solution; in some cases, both are required.

Administration of an enema against fecal impaction Administration of an enema against fecal impaction.
Administration of an enema. Administration of an enema.

Laxatives should not be given to a patient who is fecally impacted, because they may provoke vomiting and severe crampy abdominal pain. In addition, these symptoms cause the patient to become reluctant to take laxatives in the future. Therefore, the colon must be empty before laxatives are started.

Postdisimpaction administration of laxatives and enemas

Once the patient has been disimpacted, an amount of laxative (usually a senna derivative) is given, determined on the basis of the information the parents provide regarding the previous response to laxatives, as well as on the size of the colon on contrast enema. A dose is chosen, and the patient is observed for 24 hours. Water-soluble fiber is added to provide bulk and make the laxative more effective.

If the patient does not have a bowel movement within 24 hours following laxative administration, the dose was insufficient. The amount of laxative is then increased, and an enema is also administered in order to remove the stool produced during the previous 24 hours. The basic rule is that the stool in these patients with extreme constipation should never remain in the rectosigmoid longer than 24 hours, because it becomes hard and is more difficult to expel in the following days.

The routine of increasing the amount of laxatives and administering an enema every night until the goal (ie, the production of bowel movements and the complete emptying of the colon) is achieved is continued.

Radiography is performed on the day in which the patient has a bowel movement (which is usually with diarrhea) to ensure that the bowel movement was effective, meaning that the patient completely emptied the rectosigmoid. If the patient passed stool but did not completely empty the rectosigmoid, the amount of laxatives should be increased. Adding water-soluble fiber to give the stool a little bulk can help: The stool gets to the right consistency so that the patient can feel it, and the correct amount of laxative pushes out the stool.

Occasionally, in the process of increasing the amount of laxatives, patients may vomit before any positive effect is achieved. In these patients, a different medication may be tried to see if it is better tolerated. Usually, though, this means that the patient needs more sophisticated testing to determine which additional approach to treatment may be more effective.

Some patients vomit all types of laxatives, feel very sick, have severe cramps, and are never able to reach the amount of laxative capable of producing a bowel movement that empties the colon. Such patients are also candidates for additional testing and, possibly, surgical intervention. Usually, though, it is possible to find the dosage that the patient needs to empty the colon completely, as demonstrated radiologically. Once that amount has been reached, the patient can generally be expected to stop soiling.

If bowel management fails or if it severely affects a patient's quality of life, then the treating physician should determine that the patient has failed medical management. [10] At this point, further testing is required to determine the next steps. [11]

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Surgical Therapy

Indications for surgery

Bowel management is indicated in patients with fecal incontinence after surgical repair of imperforate anus or Hirschsprung disease. It is also used in patients who are continent after surgical repair but are experiencing constipation. In addition, patients with functional (idiopathic) constipation who fail bowel management may require surgical intervention. [12] The two procedures described for bowel management are colonic resection and access for antegrade enemas.

Before surgery is considered, a full motility evaluation is indicated (colonic and anorectal manometry) in patients with functional constipation who have failed medical management. This will help determine which patients would benefit from botulinum toxin, biofeedback, colonic resection plus an antegrade option, or only an antegrade option. [11]  (See the image below.)

Treatment options for severe pediatric constipatio Treatment options for severe pediatric constipation after failure of maximal medical therapy. CMAN = colonic manometry; EAS = external anal sphincter; IAS = internal anal sphincter.

Children with Hirschsprung disease who have obstructive symptoms need a full evaluation for the cause of the symptoms. The remaining patients should do well with stimulant laxatives and water-soluble fiber. In cases where the dentate line is lost and the sphincters damaged, an antegrade option may be indicated.

Some children with anorectal malformations have laxative or enema requirements that have a negative impact on their quality of life. These patients may benefit from a sigmoid colectomy in combination with an antegrade enema option. In such cases, it is vital to preserve the rectum, or else the situation may be made worse. At the time of the colectomy, the surgeon needs to preserve the blood supply to the rectum in a post–posterior sagittal anorectoplasty (PSARP) patient, which can be difficult. Clear distal vessels should be visualized in the pelvis before the level for resection is determined. 

In children with idiopathic constipation, surgical indications are determined on the basis of clinical examination, contrast enema, and motility testing. Patients with internal anal sphincter achalasia benefit from injection of botulinum toxin into the internal sphincter. Patients with pelvic floor dyssynergia may benefit from biofeedback alone or a combination of biofeedback and botulinum toxin. Colonic manometry, along with an assessment of the patient's clinical condition, is used to determine surgical treatment.

In patients with failure to thrive, usually seen with diffuse colonic dysmotility, a temporizing ileostomy may be of benefit.  Colonic manometry, sitz marker testing, or scintigraphy is used to assess for this dysmotility. The colon can be retested after 6-12 months; often, a shorter segment of dysmotile colon remains. Ileostomy closure can then be combined with colonic resection and an antegrade enema option. 

In patients with segmental colonic dysmotility and a dilated or redundant sigmoid colon, a decision must be made between an antegrade enema option alone or an antegrade option in combination with sigmoid resection. Generally, short segments of dysmotility in combination with limited redundancy can be managed successfully with an antegrade enema alone. 

Patients with longer segments of dysmotility or redundancy respond better to colonic resection in combination with an antegrade enema option. For patients in whom antegrade enema option alone is tried, a laxative trial may prove unsuccessful in the future. These patients may respond to sigmoid resection. 

Sigmoid resection

Sigmoid resection may be indicated in a small subset of patients who are continent but have a huge laxative requirement. In this group of patients, if a megasigmoid is revealed on the contrast enema or confirmed by colonic manometry, resection of the sigmoid colon (and sometimes the left colon as well) can be performed to reduce the laxative requirement and improve quality of life.

The most dilated part of the colon, which is also unresponsive to colonic manometry, is resected. The nondilated part of the colon has normal motility and is anastomosed to the rectum. The very distal rectum is preserved. This can best be done laparoscopically. [13]

Generally, the patients who improve the most are those who have a more localized form of megarectosigmoid. Patients with more generalized forms of dilated colon do not respond as well to resective therapy. They may require resection of a longer segment of colon or may neeed to be managed with a temporizing ileostomy until the abnormal segment is more localized. [14]

Appendicostomy or cecostomy

In patients who are fecally incontinent, a bowel management program with a daily enema is the ideal treatment. The rectal route may be problematic in older children who require enemas: They tend to seek independence and do not want their parents to give them enemas. In these patients, a continent appendicostomy [15] (Malone procedure) or cecostomy [16] for antegrade rectal washout can be performed.

The operation involves connecting the appendix to the abdominal wall and fashioning a valve mechanism that allows catheterization of the appendix but avoids leakage of stool through it. Some authors insert a cecostomy tube, which requires a synthetic tubing material that enters the cecum for the same goal of performing enemas. Both procedures have been laparoscopically performed. [17]

If the patient has had the appendix removed, a neoappendix can be created with a cecal flap. This may be useful on a temporary basis (up to 1 year) in patients with functional constipation. Thereafter, these patients may require further interventions if a laxative trial proves unsuccessful.

Regular follow-up and reassessments are necessary. Often, the volume of enema must be adjusted. Abdominal radiography helps the surgeon assess the actual cleanliness of the colon. Some patients prefer anal irrigation with the Peristeen system (Coloplast, Minneapolis, MN), which also allows a level of independence but still requires a rectal access route.

Sacral nerve stimulation (SNS) has been used to treat constipation in children. [18]  A study by Lu et al found that SNS led to a decrease in antegrade continence enema usage in 22 children with severe constipation. [19]  Further study is required to determine which other patients may benefit the most from SNS.

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Complications

Complications of a colonic resection include anastomotic leakage and stricture. These complications are the same as those typically faced in colon resections for other clinical situations; however, they should be rare in this setting.

Complications of appendicostomy include stricture and leakage, which usually necessitate a revision of the stoma.

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