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Constipation
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Sorangel Diaz

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Khaled Bittar

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Magda Mendez

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7/26/2021 11:04:41 PM

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Continuing Education Activity

Functional constipation is a prevalent condition in childhood, about 29.6% worldwide. In the United States, represents 3% to 5% of pediatric
visits and a considerable annual health care cost. Most children do not have an etiological factor, and one third continue to have problems
beyond adolescence. Up to 84% of functionally constipated children suffer from fecal incontinence, while more than one-third of children
present with behavioral problems primary or secondary due to constipation. Pathophysiology underlying functional constipation is
multifactorial and not well understood. Factors that may contribute to functional constipation include pain, fever, dehydration, dietary and fluid
intake, psychological issues, toilet training, medicines, and family history of constipation. Chronic idiopathic constipation is characterized by
lack of periodicity in defecating, difficulty or pain during defecation without an identifiable organic cause, such as physiological, anatomical,
radiological, or histological. Even though this is a common problem in children, an underlying cause is identified in less 5% of cases. This activity
describes the clinical evaluation of a patient with constipation and explains the role of the health professional team in coordinating the care of
patients with this condition.

Objectives:

Outline the various etiologies that can lead to a patient presenting with constipation.
Review the criteria and examination methods to determine a diagnosis of constipation.
Discuss the various treatment options for constipation based on etiology.
Summarize the clinical evaluation of a patient with constipation and explains the role of the health professional team in coordinating the
care of patients with this condition.

Introduction
Functional constipation is a prevalent condition in childhood, about 29.6% worldwide. In the United States, represents 3% to 5% of pediatric
visits and a considerable annual health care cost. Most children do not have an etiological factor, and one third continue to have problems
beyond adolescence. Up to 84% of functionally constipated children suffer from fecal incontinence, while more than one-third of children
present with behavioral problems primary or secondary due to constipation. Pathophysiology underlying functional constipation is
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present with behavioral problems primary or secondary due to constipation. Pathophysiology underlying functional constipation is
multifactorial and not well understood. Factors that may contribute to functional constipation include pain, fever, dehydration, dietary and fluid
intake, psychological issues, toilet training, medicines, and family history of constipation.[1][2][3]

Chronic idiopathic constipation is characterized by lack of periodicity in defecating, difficulty or pain during defecation without an identifiable
organic cause, such as physiological, anatomical, radiological, or histological. Even though this is a common problem in children, an underlying
cause is identified in less 5% of cases.

Etiology
Causes of constipation may be divided into following broad categories:

1. Functional (Non-Organic) or Retentive: which includes constipation due to fecal withholding behaviors and when all organic causes
have been ruled out.
2. Anatomic causes include anal stenosis or atresia, anteriorly displaced anus, imperforate anus, intestinal stricture, anal stricture.
3. Abnormal musculature related causes include prune belly syndrome, gastroschisis,  down syndrome, muscular dystrophy.
4. Intestinal nerve abnormality-related causes include Hirschsprung disease, pseudo-obstruction, intestinal neuronal dysplasia, spinal
cord defects, tethered cord, spina bifida
5. Drugs like anticholinergics, narcotics, antidepressants, lead, vitamin D intoxication.
6. Metabolic and endocrine causes like hypokalemia, hypercalcemia, hypothyroidism, diabetes mellitus (DM), or diabetes insipidus.
7. Other causes include celiac disease, cystic fibrosis, cow milk protein allergy, inflammatory bowel disease, scleroderma, among
others.

Epidemiology
Constipation can occur in any age group starting from newborn to older people; overall, it is seen more commonly in females than males. Also,
the non-white population has been reported to have a 30% higher prevalence than the white population.[4][5][6]

The pattern and frequency of defecation depend on a child’s age. During neonatal period and early infancy, bowel movements can present more
than 4 times per day, eventually trending down to 1 to 2 per day by toddler age. At this point, children usually have achieved voluntary control of
their sphincter. Hence, there is a correlation between bowel movements and age.

Pathophysiology
The cause of constipation is multifactorial. The problem may arise in the colon or rectum or it may be due to an external cause. In most people,
slow colonic motility that occurs after years of laxative abuse is the problem. In a few patients, the cause may be related to an outlet
obstruction like rectal prolapse or a rectocele. External causes of constipation may include poor dietary habits, lack of fluid intake, overuse of
certain medications, an endocrine problem like hypothyroidism or some type of an emotional issue.

Factors involved in constipation include:

low fiber diet

Caffeine abuse
Overuse of alcohol
Medications
Endocrine disorders (hypothyroid)
Neurologic disease (neuropathy)
Psychological issues

History and Physical

Rome IV criteria establish functional constipation when 2 or more of the following are present for at least one month for infants and children up
to 4 years. For children older than 4 years of age, symptoms should last for at least 2 months:

Two or fewer bowel movements per week

At least one episode of fecal incontinence per week after the child has acquired complete bowel control
History of extensive fecal retention or withholding behavior by the child
Having hard and painful stools
Large fecal mass on digital rectal examination
Large in diameter of stools that cause rectal outlet obstruction

Careful history and examination are usually sufficient to make a diagnosis. A thorough history is recommended as part of a complete evaluation
of a child with constipation. However, the answer to which aspects of the clinical history are most pertinent are not defined. Paramount
information includes the time after the birth of the first bowel movement, the period the condition has been present, the incidence of bowel
movements, consistency and the size of the stools, whether defecation is painful, whether blood is present on stool or toilet paper, and if
defecation is associated with abdominal pain. Also, is important to inquire about soiling, which can be mistaken for diarrhea in some parents.
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Medications can be associated with constipation, such as opiates, sucralfate, antacids, among others. A psychosocial history is important to
evaluate the family structure, the number of members living at home and child relationship to them, interaction with his peers and the possibility
of abuse.

The physical exam should include an assessment of “alarm” signs and symptoms (in other words, fever, abdominal distention, anorexia, nausea,
vomiting, weight loss, or poor weight gain). Bloody diarrhea in an infant with constipation could be an indication of a diagnosis such as
Hirschsprung disease. On abdominal examination, distention or a palpable “mass” may be appreciated in the lower abdomen. A rectal exam
should be performed to identify the presence of impacted stool or intrarectal mass. Visual and digital anal inspection to ensure normal size and
positioning of the anal opening and to assess for rectal prolapse.

Evaluation
The routine use of any specific imaging or laboratory test in the diagnosis of pediatric functional constipation is not recommended. However,
when symptoms fail to improve with a conventional medical approach, the further diagnostic evaluation may clarify possible causes and help
guide therapy. Such diagnostic tests include anorectal manometry, colonic manometry, colonic transit studies and imaging such as x-ray and
ultrasound.[7][8]

Anorectal manometry evaluates motor and sensory anorectal function to identify potential causes of constipation or fecal incontinence.
Hirschsprung’s disease diagnosis is aid by this test, but gold standard diagnosis continues to be a rectal suction biopsy.

Colonic manometry consists of the colonoscopic insertion of a catheter throughout the length of the colon to measure segmental pressures.
This diagnostic modality helps identify neurogenic and myogenic causes of constipation. There is no specific motility pattern is diagnostic of
idiopathic constipation.

Colonic transit studies use radiopaque markers to assess the speed of intestinal transit. This can help identify anatomic sites of fecal retention
and slow transit.

Overall, plain abdominal radiograph does not add to the history and physical exam. It may help to assess stool collection in the bowel when
patients are obese, refuse a digital rectal exam, or when it is contraindicated. However, an abdominal radiograph is neither sensitive nor specific
to diagnose constipation.

Treatment / Management
Management for constipation includes medical supervision, dietary instructions, behavioral changes and instructions regarding toilet training. A
normal fiber intake, fluid intake, and physical activity level are recommended, and the routine use of prebiotics or probiotics is not
recommended in the treatment of childhood constipation. The non-pharmacological intervention consists of demystification, explanation, and
guidance for toilet training in those children with a developmental age of a least 4 years.[9][10][11]

Laxatives represent first-line treatment for childhood constipation and, if an adequate regimen is implemented, they often have a symptomatic
improvement. Consensus guidelines recommend daily polyethylene glycol (PEG) at a dose of 1 to 1.5 gm/kg per day for 3 to 6 days for initial
fecal disimpaction, followed by a daily maintenance dose of 0.4 gr/kg per day for at least 2 months to prevent re-accumulation. A stimulant
laxative should be added if PEG alone does not cause disimpaction after 2 weeks of treatment.

Polyethylene glycol is reported to be effective in some patients. The FDA has also approved prucalopride and lubiprostone for chronic
idiopathic constipation. However, there continues to be a debate about the safety of these agents in the long run and caution is advised against
starting patients on these drugs.

Biofeedback has improved defecation dynamics but does not affect constipation. Hence this approach has not been supported for
management of idiopathic constipation in children.

Sacral nerve stimulation is a modality that has been used to treat refractory constipation, helping extrinsic neural control of large bowel and
modulating inhibitory reflexes. This has improved the defecation frequency in some children with functional constipation, but effects last less
than 6 months in a large group of patients.

Surgical management is reserved for patients with refractory to medical interventions. At least 10% of children with functional constipation
referred to a pediatric surgeon will require an operation. The surgical treatment goal is to produce symptom alleviation. Surgical options may
include anal procedures, antegrade enemas, colorectal resection, and intestinal diversion.

Differential Diagnosis
Before making the diagnosis of functional constipation, these possible etiologies should be excluded: anorectal malformations, pelvic/rectal
masses, rectal prolapse, rectocele, dysfunctional voiding, pelvic floor dyssynergia, internal anal sphincter hypertonicity or achalasia. Colorectal
conditions should be ruled out, including visceral myopathies or neuropathies, as well as Hirschsprung disease. Systemic conditions,
psychosocial issues, drugs or toxins need to be identified. Other conditions to explore include spinal cord anomalies, cystic fibrosis, connective
tissue disorders, hypothyroidism, DM, hypercalcemia, hypokalemia, Celiac disease, cow’s milk protein allergy.

Prognosis
Most pediatric patients are managed with medical therapy, and most of them will improve. However, at least 30% will persist to be symptomatic
until adulthood. Factors that are associated with a worse prognosis are female gender, older age of onset, longer time between symptom
presentation and starting therapy, and longer colonic transit time.
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In adults constipation has a poor prognosis; it seriously affects the quality of life. In many cases, treatments do not work and even when they
work, the benefits are short-lived.

Complications
Abdominal discomfort or cramps
Poor quality of life
Hemorrhoids
Anal fissures
Damage to the pelvic floor
Fecal incontinence
Urinary retention
Stercoral perforation
Rectal prolapse
Volvulus
Fistula in Ano

Enhancing Healthcare Team Outcomes

Constipation is seen in patients of all ages and the causes are diverse. The condition affects millions of people and the treatment s overall
unsatisfactory -hence the disorder is best managed by an interprofessional team with an interprofessional approach.

The primary care providers including the pharmacist, nurse practitioner should educate the patient on lifestyle modification. A diet high in fiber
is essential. In addition, the patient must be told to refrain from using laxatives, avoid drugs that cause constipation and participate in regular
exercise. Drinking ample water and avoiding too much alcohol and coffee may also help. For those habituated to laxatives, a gastroenterology
consult is necessary.[12][13]

If laxatives are prescribed, the pharmacist should assist the team by educating the patient regarding the risks and benefits.

A dietary consult may be necessary to educate the patient on what foods to eat. If constipation persists, patients may be tried on
pharmacological therapy. However, it is vital that a serious organic disorder is ruled out first.

Outcomes

Once constipation is diagnosed, compliance with the diet and medical therapy is essential to reverse the disorder. However, in many people
recurrence of constipation is common and this is chiefly due to lack of compliance with the diet. A significant number of people can become
disabled because of chronic constipation, and the quality of life can be poor. A few patients who fail to respond to medical management may
need to undergo total abdominal colectomy; however, patient selection is vital in order to get a good outcome. The most difficult patients are
those addicted to laxatives, who will not change their lifestyle and continue to use a variety of laxatives.[2][14]

References

[1] Hasler WL,Wilson LA,Nguyen LA,Snape WJ,Abell TL,Koch KL,McCallum RW,Pasricha PJ,Sarosiek
I,Farrugia G,Grover M,Lee LA,Miriel L,Tonascia J,Hamilton FA,Parkman HP,Gastroparesis Clinical
Research Consortium., Opioid Use and Potency Are Associated With Clinical Features, Quality of Life,
and Use of Resources in Patients With Gastroparesis. Clinical gastroenterology and hepatology : the
official clinical practice journal of the American Gastroenterological Association. 2019 Jun     [PubMed
PMID: 30326297]

[2] Almario CV,Ballal ML,Chey WD,Nordstrom C,Khanna D,Spiegel BMR, Burden of Gastrointestinal
Symptoms in the United States: Results of a Nationally Representative Survey of Over 71,000
Americans. The American journal of gastroenterology. 2018 Nov     [PubMed PMID: 30323268]

[3] Levin MD, Functional constipation in children: Is there a place for surgical treatment. Journal of
pediatric surgery. 2019 Mar     [PubMed PMID: 30301605]

[4] Jin L,Deng L,Wu W,Wang Z,Shao W,Liu J, Systematic review and meta-analysis of the effect of
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probiotic supplementation on functional constipation in children. Medicine. 2018 Sep     [PubMed

PMID: 30278490]

[5] Qi Z,Middleton JW,Malcolm A, Bowel Dysfunction in Spinal Cord Injury. Current gastroenterology
reports. 2018 Aug 29     [PubMed PMID: 30159690]

[6] Chuah KH,Mahadeva S, Cultural Factors Influencing Functional Gastrointestinal Disorders in the East.
Journal of neurogastroenterology and motility. 2018 Oct 1     [PubMed PMID: 30153722]

[7] Jiang R,Kelly MS,Routh JC, Assessment of pediatric bowel and bladder dysfunction: a critical
appraisal of the literature. Journal of pediatric urology. 2018 Dec     [PubMed PMID: 30297226]

[8] Maffei HVL,Morais MB, PROPOSALS TO APPROXIMATE THE PEDIATRIC ROME CONSTIPATION
CRITERIA TO EVERYDAY PRACTICE. Arquivos de gastroenterologia. 2018 Nov     [PubMed PMID:
30184022]

[9] Larkin PJ,Cherny NI,La Carpia D,Guglielmo M,Ostgathe C,Scotté F,Ripamonti CI,ESMO Guidelines
Committee., Diagnosis, assessment and management of constipation in advanced cancer: ESMO
Clinical Practice Guidelines. Annals of oncology : official journal of the European Society for Medical
Oncology. 2018 Oct 1     [PubMed PMID: 30016389]

[10] Martinez de Andino N, Current treatment paradigm and landscape for the management of chronic
idiopathic constipation in adults: Focus on plecanatide. Journal of the American Association of Nurse
Practitioners. 2018 Jul     [PubMed PMID: 29979299]

[11] Andresen V,Layer P, Medical Therapy of Constipation: Current Standards and Beyond. Visceral
medicine. 2018 Apr     [PubMed PMID: 29888241]

[12] Veiga DR,Mendonça L,Sampaio R,Lopes JC,Azevedo LF, Incidence and Health Related Quality of Life
of Opioid-Induced Constipation in Chronic Noncancer Pain Patients: A Prospective Multicentre
Cohort Study. Pain research and treatment. 2018     [PubMed PMID: 30112202]

[13] Osuafor CN,Enduluri SL,Travers E,Bennett AM,Deveney E,Ali S,McCarthy F,Fan CW, Preventing and
managing constipation in older inpatients. International journal of health care quality assurance. 2018
Jun 11     [PubMed PMID: 29865964]

[14] Iqbal F,van der Ploeg V,Adaba F,Askari A,Murphy J,Nicholls RJ,Vaizey C, Patient-Reported Outcome
After Ostomy Surgery for Chronic Constipation. Journal of wound, ostomy, and continence nursing :
official publication of The Wound, Ostomy and Continence Nurses Society. 2018 Jul/Aug     [PubMed
PMID: 29994858]

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