CONSTIPATION
DIAGNOSIS OF CONSTIPATION – ROME III CRITERIA
ORGANIC CAUSES OF CONSTIPATION AND DIAGNOSTIC TESTS
Anorectal malformation:
- Physical examination
Chronic constipation:
- Physical examination and history
Non-retentive faecal incontinence:
- Physical examination and history*
Hirschsprung’s disease:
- Rectal biopsy*
- Anorectal manometry
- Barium enema
Neuroenteric problem:
- Colonic motility*
- Rectal biopsy
Spinal cord problem:
- Physical examination
- Magnetic resonance imaging*
- Anorectal manometry
Pelvic floor dyssinergia:
- Anorectal manometry*
Metabolic, systemic problems:
- Thyroxine, thyroid stimulating hormone*
- Tests for coeliac disease*
- Calcium*
- Sweat test*
Toxic (lead, drugs):
- Lead level, toxic screen*
Cows’ milk allergy:
- Elimination diet
- Allergy testing
*Investigations of choice.
EXAMINATION
- Avoid Per Rectal examination.
- Inspect anus for fissures or tags, infection, skin disease, anal ectopia.
- Inspect the back and neurological examination of the legs.
- Consider psychological factors.
MANAGEMENT
Education
- Parental/family education-Explain physiological basis of constipation.
- Psychosocial problems should be considered in the first meeting.
TREATMENT
1-Macrogols (polyethylene glycols)
- First line treatment
- In Chronic constipation – continue maintenance to prevent faecal impaction as below
FECAL DISIMPACTION GUIDELINES
- An escalating dose of polyethylene Glycol (PEG) is recommended as first-line treatment with a stimulant added if required.
- Review the child regularly.
- Disimpaction should generally be initiated orally
- Do not use rectal medications for disimpaction unless all oral medications have failed and only if the child or young person and their family consent.
- Do not administer phosphate enemas for disimpaction unless under specialist supervision .
2- Osmotic laxatives
Lactulose
- Dose: <1 year 2.5 ml bd
- 1-5 years 2.5-10 ml bd
- 5-18 years 5-20 ml bd
3- Stimulant laxatives
Sodium picosulphate
- Dose:
- 1month to 4 years =2.5-10mg daily
- 4 to 18 years =2.5-20mg daily
Docusate sodium
- Dose:
- 6 months to 2 years -12.5 mg tds
- 2 -12 years =12.5-25mg tds
- 12-18 years =Up to 500mg daily in divided doses
Bisacodyl
- Dose: 4-18 years 5 -20 mg daily orally
- 2-18 years 5-10mg suppository.
Senna (Syrup 7.5mg/5ml)
- Dose:
- 1 month to 4 years 2.5-10ml
- 4-18 years 2.5-20ml
Senna (Tablets / 7.5mg)
- Dose:
- 2-4 years- ½ – 2 tablets once daily
- 4-6 years -½- 4 tablets once daily
- 6-18 years- 1-4 tablets once daily
MAINTENANCE THERAPY( Always follows Disimpaction therapy)
- Aim of treatment, (NICE), is to be symptom-free with regular soft bowel actions
- Should be commenced immediately, initially at half the dose required for disimpaction.
- Laxative treatment needs to be tailored to the child
- Give parents the support to allow them to vary the laxative dose in response to their child’s symptoms
- Once improvement is seen, laxatives should be gradually reduced and never stopped suddenly.
- Relapses are common and may need to be treated with increasing doses of laxatives.