Chronic Constipation
What is it?
Chronic constipation is a common condition that is featured by infrequent or difficulty in passing motions. Typically, constipation sufferers have fewer than 3 bowel movements per week, straining, hard stools and incomplete evacuation of stool passage.
How common is it?
Chronic constipation is one of the most common conditions we see in the clinic. Nearly one in three children suffers from constipation during their childhood. It is more common in teenage girls than boys.
What are the causes?
There are many causes of constipation such as habitual (stool withholding, ignoring defaecation sensation), poor diet, inactivity, hypothyroidism, coeliac disease and delayed onset food allergy. A high proportion of children with constipation do not have organic causes. This is commonly called idiopathic constipation.
What are the signs and symptoms?
The clinical manifestations of constipation can be varied. These include infrequent bowel movement, passing rabbit dropping or abnormally large stool, stool soiling caused by lack of defaecation sensation due to megarectum formation, excessive straining during defaecation, incomplete defaecation sensation, loss of appetite, early satiety, abdominal pain during or shortly after mealtime and nausea. Severe constipation can also cause vomiting.
A normal abdominal examination does not exclude constipation as the bowel is located in the retroperitoneum (abdominal cavity). In severe constipation the clinician sometimes can feel a suprapubic mass.
How is diagnosed?
A detailed history taking is often sufficient to diagnose constipation. Constipation can be diagnosed with an abdominal ultrasound scan by an experienced radiologist. Abdominal x-ray is sometimes necessary to check for faecal loading in children who have severe unexplained abdominal pain. A bowel transit marker study is useful in assessing the motility of the large bowel.
What are the treatments?
In one in three children with constipation is caused by underlying delayed onset food allergy. Therefore, a period of exclusion diet such as dairy-free or wheat-free is an important step to take. By removing the offending food, the bowel movement will start to improve.
The main treatment for constipation is adequate fluid intake, a high-fibre diet and a set routine of regular toileting. Macrogol (Laxido, Movicol) is the mainstay of treatment. Sometimes in moderate constipation, patients may require a stimulant such as Sodium Picosulfate, Senokot, Docusate Sodium or Bisacodyl. In children with severe rectal blockage, an enema or suppository can be useful to evacuate the faecal loading in the rectum.
Constipation treatment with laxatives can take several weeks or months. If the constipation is caused by an underlying food allergy, the patient is often able to wean off the laxative very quickly by excluding the offending food allergen.
Early recognition of constipation during the weaning process is important. These include abdominal pain during or shortly after mealtime, incomplete defaecation sensation, excessive straining and early satiety. Parents will need to anticipate that with treatment can take weeks or even months to improve.
Important notes:
A child can still be constipated despite being on a good and varied diet, adequate fluid intake and being physically active.
Abdominal pain occurs during or shortly after mealtime is a good indicator for constipation. It is because food triggers the contraction of the bowel, and the contraction of the higher part of the bowel against the partially blocked lower part of the bowel can cause significant pain; the bigger the meal the bigger the contraction, and hence the more pain the patient will experience.
A normal stool consistency does not exclude constipation.
The typical adult stool volume is about 150grams to 200grams whereas the stool volume in a child is about 50 grams to 200 grams a day.
If the child does not achieve the target amount of stool clearance daily, over time, the excess stools will build up gradually distending the bowel. In severe cases, this will lead to megarectum formation which will lead to lack of defaecation sensation, and hence stool soiling ensues.
Constipation is one of the most difficult conditions to treat and can be very debilitating. Children with constipation often have low self-esteem, low mood, anxiety around toileting habits, poor school attendance, lack of energy, and it often has significant impact to the physical and mental wellbeing of the child and can pose a significant burden to the family.
Abrupt withdrawal of laxatives often causes rebound constipation. Laxatives need to be weaned off slowly.
Children with severe faecal impaction can also have problems with the urinary system in that it can cause enuresis or stress incontinence. The urinary symptoms will not improve until there is adequate treatment for constipation.
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