Table 4 outlines a systematic approach to the treatment of chronic constipation. This scheme assumes that any specific etiologic factors have been identified and dealt with appropriately. TABLE 4 Approach to Treatment of Chronic Constipation 1. Ensure adequate fluid intake (approximately 2.5 litres per day, i.e. roughly eight 10oz. glasses) 2. Maximize activity. 3. High fiber diet and/or bran and/or psyllium preparation. 4. Try to establish regular defecation time, eg. 20-40 minutes after breakfast or supper. Whenever possible, attempt at defecation should be made in sitting position on commode or toilet; bedpan should be avoided. 5. If no spontaneous bowel movement, glycerin suppository on second day and at two-day intervals thereafter, approximately 30 minutes before planned bowel movement. 6. Attempt to wean from suppositories once regular pattern of bowel … Read entire article »

Table 3 presents a classification of commonly used oral laxatives. TABLE 3 Oral Laxatives Stimulant Laxatives 1. Anthraquinone Laxatives senna (eg. Senokot) cascara (eg. together with aloe in Nature’s Remedy) danthron (eg. Modane) 2. Diphenylmethane Laxatives phenolphthalein (eg. Ex-lax, Feen-a-mint) bisacodyl (eg. Dulcolax) 3. Castor oil Saline Laxatives magnesium hydroxide (eg. Milk of Magnesia) magnesium citrate (eg. Citro-Mag) Emollient Laxatives dioctyl sodium sulfosuccinate (eg. Colace) dioctyl calcium sulfosuccinate (eg. Surfak) Bulk-forming Laxatives bran psyllium preparations (eg. Metamucil) methylcellulose, sodium carboxymethylcellulose Lactulose (eg. Chronulac) Stimulant laxatives are thought to act on the intramural nervous plexus or intestinal smooth muscle. There is some reason to be concerned that prolonged use of any of the stimulant laxatives may damage the myenteric plexus, thereby impairing bowel function. However, at this point there is no direct evidence to implicate the diphenylmethane group. The anthraquinone and diphenylmethane laxatives act in six to ten hours. Their action is confined … Read entire article »

Why do old people become constipated? Generally for the same reasons that young people become constipated. Certainly they do not become constipated as a simple consequence of aging. There is not a shred of evidence that bowel function declines with advancing age. Although it is true that the incidence of colonic diverticula increases with age, these changes do not in themselves alter bowel function and do not correlate with constipation. The factors which may lead to constipation are listed in Table 1 in rough order of their importance in the geriatric population. Obviously, several factors may be at work in a single patient. TABLE 1 Etiologic Factors in Constipation 1. Insufficient dietary fiber 2. Inactivity/immobility 3. ‘Gut reaction’ to stress: anxiety (irritable colon syndrome) or depression 4. Drugs 5. Inadequate fluid intake 6. Laxative abuse 7. Poor muscle power (diaphragm, abdominal wall) 8. Impaired mental state … Read entire article »

What is constipation? Obviously it concerns frequency and consistency of bowel movements and degree of difficulty in passing stools. Consistency is more important than frequency. Based on British studies the normal range is usually taken to be from three bowel movements per day to three per week. That range includes about 99% of the population. Clearly some individuals within the range will prove to be constipated when consistency and difficulty in passing stools are taken into account, while others lying outside the range will be seen to have normal bowel function. However, the correlation between stool softness and frequency is high. The record for rectal continence is held by a man whose feat was reported in a 1902 article entitled “Unprecedented case of constipation“. After 368 days without a bowel movement the … Read entire article »

Many old people seem to regard bowel function as a kind of health barometer and the maintenance of regular bowel action as a form of insurance against ill health. Bertrand Russell, for example, is reported to have believed that his longevity was largely due to efficient bowel function. Constipation is often viewed as both a reflection of failing health and as a disease in itself, capable of producing all manner of unpleasant symptoms from insomnia to bad breath. Although constipation does not appear to be more common in the elderly, use of laxatives undoubtedly is. Several British studies have shown increasing use of laxatives with age. The available evidence suggests that age differences in laxative use may not reflect differences in need but rather generational differences in attitude toward bowel function … Read entire article »

Acute constipation Acute constipation usually responds well to dietary measures. Constipation induced by whole cow’s milk will improve if formula is reintroduced for a few months. The addition of fruits such as prunes, apricots, and plums is helpful. Lactose or lactulose can be added to formula. If constipation has led to painful defecation, the pain retention cycle must be broken. The addition of a lubricant (mineral oil) or a stool softener like docusate sodium is sometimes necessary. These should be continued for several months so that the child no longer associates defecation with pain. Chronic severe constipation Chronic severe constipation, with or without encopresis, needs a systematic long-term approach. 1. Family education: the physiology of the problem must be explained to both child and parents, who need to acknowledge that the fecal soiling … Read entire article »

Extensive investigations are rarely indicated. All investigations should be guided by the history and clinical findings. Table 3 lists the appropriate investigations for different conditions. Table 3. Investigations For The Child With Constipation SIMPLE CONSTIPATION • None SEVERE CONSTIPATION WITH ENCOPRESIS • Flat plate x-ray of abdomen to assess fecal loading if results of abdominal examination are negative and rectum is empty • Routine urinalysis and urine culture CONSTIPATION AND FAILURE TO THRIVE • Thyroid function studies • Complete blood count • Erythrocyte sedimentation rate • Stool for occult blood and leukocytes CONSTIPATION AND URINARY TRACT INFECTIONS • Renal ultrasound • Voiding cystourethrogram SUSPECTED HIRSCHSPRUNG’S DISEASE • Barium enema: limited study of an unprepared bowel • Prompt referral to a pediatric surgeon for … Read entire article »

The word encopresis was coined by Weissenberg in 1926, who considered this the equivalent of enuresis. Now encopresis is defined as the repetitive passage of formed, semi-formed or liquid stool into the clothing, with no demonstrable organic cause, in a child who should be toilet-trained. Constipation can cause encopresis. Fecal impaction of the rectum leads to stretching of the rectal wall as well as to stretching and shortening of the anal canal. Normal sensations disappear, and normal function of rectum and sphincters is impaired. Involuntary passage of soft stool around the impaction results. The parents often think that the child has diarrhea. Medical treatment is often not sought for a long time. Many parents have used punitive measures to control the problem without success. In most instances, psychologic problems are the result of … Read entire article »

Age-related problems with bowel function can be classified as those affecting new-borns and infants, those affecting toddlers and preschoolers, and those affecting school-aged children. Fortunately, some of these problems can be prevented. Newborns and infants Infrequent stools during the first few weeks of life in a breast-fed baby who is not gaining weight suggest inadequate milk intake. On the other hand, it is normal for a healthy, thriving, breast-fed baby to have only one bowel movement every 7 to 10 days. Both these situations are often interpreted by the parents as constipation. Even more parental concern is triggered by the baby straining and turning red to produce a normal, soft bowel movement. Treatment with suppositories, rectal stimulation, or formula changes is often initiated by parents – with or without a physician’s … Read entire article »

Hirschsprung’s disease is the result of congenital absence of the parasympathetic ganglion cells of the intramural plexus of the distal colon and rectum. This defect leads to persistent contraction of the affected bowel segment. Typical Hirschsprung’s disease is easily distinguished from idiopathic constipation. Infants with Hirschsprung’s disease exhibit delayed passage of meconium and infrequent stools. This, associated with marked abdominal distention and progressive vomiting of bile, presents a classic picture of bowel obstruction. The rectum is empty and withdrawal of the examining finger is often followed by an explosive discharge of stool and gas. Rarely, the presentation is atypical and the diagnosis is delayed for several years. Features that differentiate chronic constipation from Hirschsprung’s disease are summarized in Table 1. Infants with this disease are always at risk of developing … Read entire article »