Constipation faecal loading

K59.0

DESCRIPTION

Constipation: the infrequent passage of hard stools. This is often due to behavioural retention following previous painful episodes of defaecation (functional constipation), but may also be due to organic causes (metabolic, endocrine, neurogenic, lower bowel abnormalities and medication side-effects).
Constipation-associated faecal incontinence: the involuntary leakage of small amounts of soft or watery stools secondary to faecal loading.

DIAGNOSTIC CRITERIA

Rome IV Criteria:

Infants up to 4 years of age should have at least two symptoms for 1 month prior to diagnosis and those over developmental age 4 years should have at least two symptoms present for the previous 2 months:

  • Two or fewer defaecations per week.
  • At least 1 episode of faecal incontinence per week.
  • Retentive posturing or stool retention.
  • Painful or hard bowel movements.
  • Presence of a large faecal mass in the rectum.
  • Large diameter stools that may obstruct the toilet.

LoE: III[2]

LoE: III[3]

GENERAL AND SUPPORTIVE MEASURES

  • Determine and treat the underlying cause.
  • Treatment involves 3 steps:
    • initial clearance of stools,
    • prevent re-accumulation of hardened retained stool, and
    • retraining of the gut to achieve regular toilet habits.
  • Management is long-term and requires the active involvement of the parents.

MEDICINE TREATMENT

Initial therapy

(Disimpaction if indicated)

  • Phosphate-containing enema (sodium phosphate 6 g, sodium biphosphate 16 g/100mL).
  • Age 2–5 years: 32 mL.
  • Age 5–11 years: 64 mL.
  • Repeat once, if necessary.
    OR
  • Polyethylene glycol 59 g/L solution with sodium sulphate and electrolytes, oral/ nasogastric tube, 10–25 mL/kg/hour until clear fluid is passed rectally.

Note:
No additional ingredient should be added to the solution, e.g. flavourings or sugar containing cold drinks.

Maintenance therapy

The child and parents should be counselled and educated about behaviour modification (regarding toilet habits) and diet changes (additional natural fibre from fruit, vegetables and bran).

(a) Osmotic laxative

  • Lactulose 0.5-1 mL/kg/dose once or twice daily.
    AND/OR

(b) Stool softener

  • Liquid paraffin, oral, 1-3 mL/kg/day. Single or divided dosage.
  • Do not use in children under 1 year or those with neurological conditions or swallowing disorders
    AND/OR

(c) Bulk-forming agent

  • Ispaghula husk, oral, 1.75–3.5 g, stirred in water with breakfast.

If faecal loading was present, maintenance therapy should be continued for months to years.

REFERRAL

  • Suspected organic cause e.g. constipation from birth in a breast-fed baby.
  • Inadequate response to therapy.