Constipation

Causes include

Diagnoses

General measures

Investigations

Treatment

Constipation is the infrequent passage of hard stools. This is often due to behavioral retention following previous painful episodes of defecation or other somatic causes and overuse of certain medications. 

Faecal soiling: the involuntary leakage of small amounts of soft or watery stools secondary to faecal loading. 

Causes include: 

• Incorrect diet 
• Psychogenic disorders 
• Lack of exercise 
• Chronic use of enemas 
• Certain drugs 
• Uncommon: Metabolic, endocrine (hypothyroidism), neurogenic and lower bowel abnormalities 

Diagnoses 

• History of infrequent passage of hard stools. 
• Non-tender deformable faecal masses palpable. 
• Complicated cases with diagnostic uncertainty, confirm on a straight abdominal X-ray. 

General measures 

• Determine and treat the underlying cause 
• Treatment involves 3 steps: 
  • Initial clearance of stools 
  • Prevent re-accumulation of hardened retained stool 
  • Retraining of the gut to achieve regular toilet habits 
• Management is long-term, and requires the active involvement of the parents 

Investigations: 

• Urine dipstix 
• AXR (Complicated cases with diagnostic uncertainty only) 
• Exclude rare causes only if clinical signs (hypothyroidism, Hirschsprungs, ano-rectal malformation) 

Treatment 

• Faecal clearance 
  • Phosphate-containing enema (Golytely / Klean-prep) 20ml/kg/hour until stools are clear. (In small children be careful of severe electrolyte shifts!) 
  • Paediatric fleet enema PR stat 
• Maintenance 
  • Explain to parents bowel re-education may take months 
  • Encourage and involve child 
  • Toilet after meals regardless of whether need is present 
  • Star charts with rewards for success 
  • Additional fluid intake 
  • Dietician referral if available 
  • High fibre diet : bran, fruits / veggies, whole-grains 
  • Additional fibre: Ispaghula husk, oral, 1.75–3.5 g, stirred in water with breakfast. 
  • Lactulose 0.5 mL/kg/dose 12 hourly (Alternative Sorbitol 5-15ml) 
  • If no resolution add Senokot 7.5mg M/W/F PO (1 Tab on three days per week) or Bisacodyl (Dulcolax) 5mg M/W/F PO in children 6 years or older.