Constipation

INTRODUCTION

The Rome III criteria define constipation as having 2 or more of the following, for at least 12 wks:

• infrequent bowel action <3 per week

• feeling of unsatisfied emptying of bowel >25% of time

• passage of lumpy or hard stools at least 25% of time

• use of manual manoeuvres >25% of time

• sensation of anorectal blockage >25% of time

Colorectal cancer must be ruled out in adults.

Alarm symptoms

• Recent constipation in >40 years of age

• Rectal bleeding

• Family history of cancer

IDIOPATHIC (FUNCTIONAL) CONSTIPATION

The commonest type is functional constipation, primarily due to slow transit, dyssynergic defecation and lifestyle, e.g. low fluids, a faulty diet and bad habit.

Constipation in children

This is defined as having ≥2 of the following over the previous 2 mths:

• <3 bowel motions per wk

• >1 episode of faecal incontinence per wk (previously referred to as encopresis)

• large stools in rectum or palpable on abdominal examination

• retentive posturing and witholding behaviour

• painful defecation

Faecal incontinence

This is the passage of stool in an inappropriate place in children who have been toilet trained. It can present with soiling, due to retention with overflow of liquid faeces (spurious diarrhoea).

Management in children

It is nearly always functional (>95%), but rule out Hirschsprung disorder and anal fissure in infants.

• Encourage relaxed child–parent interaction with toilet training (e.g. ‘after breakfast habit’ training). Advise on correct posture and position.

• Establish an empty bowel: remove any impacted faeces with microenemas (e.g. Microlax).

• Advice for (parents of) children >18 mths:

  • – Drink ample non-milk fluids each day (be cautious of cow’s milk)

  • – Use prune juice (contains sorbitol)

  • – Get regular exercise (e.g. walking, running, outside games or sport)

  • – Eat high-fibre foods (e.g. high-fibre cereals, wholegrain bread, fresh fruit with skins left on where possible, dried fruits such as sultanas, apricots or prunes, fresh vegetables)

• Use a pharmaceutical preparation as a last resort to achieve regularity. If constipation is of brief time treat for 3 mths, if chronic treat for 6 mths.

• First line: osmotic laxative, e.g. lactulose:

  • – 1–5 yrs: 10 mL/day

  • – >5 yrs: 15 mL/day

  • – >12 yrs: 15 mL bd or

  Macrogol 3350 with electrolytes (Movicol):

  • – ...