Medical Management Considerations
Chronic constipation is a condition in which the stool accumulates, hardens, blocks up, and/or is difficult to expel, which may lead to three or more days between bowel movements. Obstipation is severe constipation leading to colonic dilatation. Chronic constipation is a symptom of an underlying problem and an issue for many people with developmental disabilities. Chronic constipation is much more prevalent among people with developmental disabilities than the general population, for which constipation is still the most common digestive complaint; for example, the incidence of constipation is 74% among children with neurodevelopmental disabilities.
The physical assessment of the person should be conducted to identify any conditions that may influence his or her bowel function and to help determine current status. This may include:
In addition, the physician may want to monitor the person for several days with the aid of a food and fluid chart and bowel chart. An abdominal X-ray can be useful in both indicating the nature of the problem and assessing the degree of constipation and, hence, the appropriate treatment.
The degree of neurologic involvement and abnormalities in defecation dynamics will guide the clinician in developing an appropriate treatment and management plan and provide some insight into the potential for normal defecation. A plan that includes a “cleaning out” phase followed by medical and dietary management as well as behavior modification is often successful. However, continence may not be a realistic possibility in people with severe disabilities. In this case, the goal of therapy is to soften the stool so it is painless to pass.
Phase I: “Cleaning Out”: Emptying the Colon and Rectum
The entire colon and rectum must first be evacuated before laxatives are administered. Enemas (which empty the distal colon only) of polyethylene glycol solution (GoLytely) or suppositories can be used. The condition may require manual disimpaction by a physician, including use of irrigation to cleanse the colon. In the case of fecal impaction—the presence of a large mass of hard stool in the rectum that results from severe constipation for several days—inpatient treatment may be required, particularly if the colon is backed up to the cecum.
The long-term prognosis of people with chronic constipation varies depending on the underlying cause of the constipation. Laxatives and fiber therapies are effective in improving bowel movement frequency, unless the constipation is caused by slow GI transit or an underlying disorder.
Drugs of Choice
Some laxative agents are used well in combination (e.g., stool softener and bisacodyl) since one drug alone often may not be sufficient. Enemas and laxatives can relieve constipation temporarily, but overuse can interfere with natural bowel muscle control and recurrent use should be avoided. In addition, overuse of mineral oil can reduce the absorption of vitamins A, D, E, and K and bring about unfavorable drug interactions.
Phase III: Surgery (if lifestyle, diet, and medication treatments are not effective)
Bishop, P.R., Nowicki, M.J. (1999). Defecation Disorders in the Neurologically Impaired child. Pediatric Annals, 28(5), 322-329.
Bohmer, C.J. et al. (2001). The Prevalence of Constipation in Institutionalized People with Intellectual Disability. Journal of Intellectual Disability Research, 45(3), 212-218.
Chong, S.K.F. (2001). Gastrointestinal Problems in the Handicapped Child. Current Opinion in Pediatrics, 13(5), 441-446.
Elawad, M.A., Sullivan, P.B. (2001). Management of Constipation in Children with Disabilities. Developmental Medicine and Child Neurology, 43(12), 829-832.
Mertz, H., Naliboff, B., Mayer, E.A. (1999). Symptoms and Physiology in Severe Chronic Constipation. American Journal of Gastroenterology, 94(1), 131-138.
Nyam, D.C. et al. (1997). Long-term Results of Surgery for Chronic Constipation. Diseases of the Colon and Rectum, 40(3), 273-279.
Tramonte, S.M. et al. (1997). The Treatment of Chronic Constipation in Adults: A Systematic Review. Journal of General Internal Medicine, 12(1), 15-24.
Batshaw, M.L., Perret, Y.M. (1986). Feeding the Dhild with Handicaps. In Children with Handicaps: A Medical Primer (2nd ed., pp. 129-137). Baltimore: Paul H. Brookes.
Behrman, R.E., Kliegmean, R.M., Jenson, H.B. (Eds.). (2000). Major Symptoms and Signs of Digestive Tract Disorders. In Nelson Textbook of Pediatrics (16th ed., p. 1105). Philadelphia: W. B. Saunders.
Borowitz, S.M. (1997). What are the Symptoms of Chronic Constipation? Retrieved May 19, 2006, from http://www.healthsystem.virginia.edu/internet/pediatrics/patients/tutorials/constipation/symptoms.cfm
Eicher, P.S. (1997). Feeding. In M. L. Batshaw (Ed.), Children with Disabilities (4th ed., pp. 621-641). Baltimore: Paul H. Brookes.
Frank, D. (1999). Constipation. In M.R. Dambro (Ed.), Griffith’s 5 Minute Clinical Consult (pp. 260-261). Baltimore: Lippincott Williams & Wilkins.
Nickel, R.E. (2000). Meningomyelocele and Related Neural Tube Defects. In R.E. Nickel & L.W. Desch (Eds.), The Physician’s Guide to Caring for Children with Disabilities and Chronic Conditions (pp. 425-476). Baltimore: Paul H. Brookes.
American Gastroenterological Association (AGA)
Phone: (301) 654-2055
International Foundation for Bowel Dysfunction
Phone: (414) 964-1799
International Foundation for Functional Gastrointestinal Disorders
Phone: (888) 964-2001
National Digestive Diseases Clearinghouse
Phone: (212) 685-3440
National Information Center for Children and Youth with Disabilities (NICHCY)
Voice/TTY: (800) 695-0285
National Institute of Diabetes, Digestive and Kidney Diseases
National Organization for Rare Disorders (NORD)
Phone: (203) 744-0100
Voice mail: (800) 999-NORD
TTY: (203) 797-9590
The Resource Foundation for Children with Challenges
Special Child: For Parents and Caregivers of Children with Special Needs http://www.specialchild.com/index.html
Society of American Gastrointestinal Endoscopic Surgeons (SAGES)
Phone: (310) 314-2404
The Tarjan Center for Developmental Disabilities at UCLA
Theodore A. Kastner, M.D., M.S.
Felice Weber Parisi, M.D., M.P.H.
Romie H. Holland, M.D.
Patrick J. Maher, M.D.
James R. Popplewell, M.D.
Patricia Samuelson, M.D.
Terrance D. Wardinsky, M.D.
Larry Yin, M.D., M.S.P.H., F.A.A.P.
Funded by a grant from the California Department of Developmental Services
For more information, contact:
Center for Health Improvement
1330 21st Street, Suite 100
Sacramento, CA 95814
This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to the California Department of Developmental Services and the Center for Health Improvement.