Chronic Constipation

BACKGROUND

Description

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.

Causes

Inadequate fluid intake/Dehydration
Inadequate fiber intake
Uncoordinated muscle contractions
Poor habitual training
Poor rectal sphincter control
Immobility (decline in muscle tone) or motor abnormalities
Lack of erect posture
Medications (e.g., anticholingergics, opiates, antacids, and antiepileptics, psychotropics)
Electrolyte abnormalities (hypercalcemia, hypokalemia)
Spinal cord dysfunction
Slow colon transit (particularly in patients with a history of laxative abuse)
Irritable bowel syndrome
Pelvic floor dysfunction
Hormonal abnormalities (hypothyroidism, diabetes)
Fear of having a bowel movement with pain, and withholding

Comorbidities

Hirschsprung disease
Cerebral palsy
Cystic fibrosis (meconium ileus equivalent)
Muscular dystrophy
Spinal cord lesions (tumors or spina bifida) or injury
Neurodevelopmental disabilities or neurological impairment
Illness or injury
Underlying lesion
Pseudo-obstruction
Psychiatric disorder

Signs and Symptoms

Abdominal pain
Difficult or painful elimination of stool
Hardened or impacted stool
Decreased volume of stool passage
Infrequent bowel movements (fewer than 3-5 times per week)
Loose stool, watery diarrhea around point of impaction
Meal refusal or loss of appetite
Nausea/Vomiting (if serious obstruction)
Abnormal bowel pattern
Bloating
Visible abdominal distention
Hard abdomen
Increase in seizure frequency, if any
Increase in self-injurious behavior
Sleepiness or fussiness

Diagnostic Considerations

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:

Assessing the mouth, condition of teeth, and swallowing with regard to the person’s tolerance of different food types (such as fruit or increased dietary fiber)
Large abdominal wall hernias, especially ventral hernias, may interfere with the generation of adequate intra-abdominal pressure that is required for the initiation of defecation.
Auscultation the abdomen to determine presence or absence of bowel sounds
Checking visually for abdominal distension
Examining abdomen for evidence of a dilated colon and hard impacted stools (a negative exam, however, does not necessarily exclude constipation)
Checking for any other conditions that may contribute to constipation (such as hemorrhoids or anal fissures)
Performing a rectal examination to determine the content of the rectum and whether stool is hard or soft and to assess possible impaction
Check thyroid-stimulating hormone levels to rule out hypothyroidism in patients refractory to dietary management.

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.

Common Associations

Increasing abdominal pressure, and thereby the risk of gastroesophageal reflux (GERD) [Return to the index for a full document on GERD]
Discomfort that can interfere with appetite, positioning, and sleep
Slow gastric emptying
Cramping

Possible Complications

Fecal impaction
Stool soiling around impaction
Rectal ulceration
Volvulus
Pulmonary aspiration [Return to the index for a full document on Aspiration]
Acquired megacolon (afunctional distention with poor colon contractions)
Cathartic colon
Fluid and electrolyte depletion (as a secondary result of laxative abuse)
Toxic megacolon

MEDICAL MANAGEMENT CONSIDERATIONS

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.

Treatment of Immediate Constipation

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.

Management of Chronic Constipation

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.

Phase I: Lifestyle and Diet Modifications

Ensure adequate fluid intake (6-8 glasses a day, non-caffeinated).
Ensure adequate fiber intake (15 gm/day from whole grain cereals, bran, and raw fruits and vegetables).
Treat somatomotor disorders.
Recommend regular movement and exercise.
Avoid or decrease anticholinergics, opiates, antacids and antiepileptics if possible.
Establish a regular bowel elimination program
Demonstrate proper posture for bowel movements (thighs flexed toward abdomen).
Advise to drink warm fluid before feedings.
Maintain record of food and fluid intake.
Maintain thorough record of frequency and characteristics of stool.
Consider recommending a mild, natural laxative like prune, apricot, or papaya juice.

Phase II: Medication (if lifestyle and diet modifications alone are not effective)

Drugs of Choice

Hydrophilic colloids (psyllium, methylcellulose, polycarbophil)
Emollient laxatives/stool softeners (docusate sodium)
Osmotic laxatives: short-term use (Milk of Magnesia, magnesium citrate, phospho-soda, lactulose, sorbitol, alumina-magnesia, GoLytely,MiraLax)

Contraindications

Any impediment to bowel transit (e.g., obstructing lesion or ileus); osmotic laxatives may result in overdistension or bowel perforation
Any acute intra-abdominal inflammatory condition
Renal and heart failure—relative contraindications

Alternative Drugs

Prokinetic agents, for refractory cases only
Lubricants
Stimulant laxatives (anthraquinones, e.g. senna [Senokot], bisacodyl, phenolphthalein, castor oil)
Hyperosmotic laxatives (polyethylene glycol [MiraLax])
Enemas (phospho-soda)
Suppositories (sodium phosphate, glycerin, bisacodyl [Ducolax])
Tegaserod maleate (Zelnorm) (for short-term treatment of women with constipation-predominant irritable bowel syndrome)

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)

Appendicostomy (Malone procedure) with antegrade continence enema (ACE)
Abdominal colectomy
Ileorectostomy
Colostomy

REFERENCES

Peer-Reviewed Journal Articles

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.

Other Publications

Batshaw, M.L., Perret, Y.M. (1986). Feeding the Dhild with Handicaps. In Children with Handicaps: A Medical Primer (2^nd 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 (16^th 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 (4^th 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.

RESOURCES FOR FAMILIES

American Gastroenterological Association (AGA)

Phone: (301) 654-2055

http://www.gastro.org

International Foundation for Bowel Dysfunction

Phone: (414) 964-1799

http://www.iffgd.org

International Foundation for Functional Gastrointestinal Disorders

Phone: (888) 964-2001

http://www.iffgd.org

National Digestive Diseases Clearinghouse

Phone: (212) 685-3440

http://digestive.niddk.nih.gov

National Information Center for Children and Youth with Disabilities (NICHCY)

Voice/TTY: (800) 695-0285

E-mail: [email protected]

http://www.nichcy.org

National Institute of Diabetes, Digestive and Kidney Diseases

http://www.niddk.nih.gov

National Organization for Rare Disorders (NORD)

Phone: (203) 744-0100

Voice mail: (800) 999-NORD

TTY: (203) 797-9590

E-mail: [email protected]

http://www.rarediseases.org

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

http://www.tarjancenter.ucla.edu

ADVISORY COMMITTEE

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.

PUBLICATION INFORMATION

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

(916) 901-9645

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.