Chronic constipation is defined as difficult or infrequent defecation lasting at least two weeks. It can be classified based on age of onset (congenital or acquired) and duration (acute or chronic). Causes include functional issues in 90-95% of cases, as well as anorectal abnormalities, neurological conditions, metabolic disorders, and certain drugs. Treatment involves complete disimpaction followed by maintenance therapy using laxatives, a high-fiber diet, and behavioral modifications like scheduled toilet sitting to prevent recurrence. Proper treatment can result in excellent improvement for many children, though some may continue to struggle with constipation into adolescence.

1. Chronic
Constipation
Dr.Vishnu Biradar
Cons. Pediatric Gastroenterologist
Pune

2. What is constipation?
NASPGAN (2006):
Defined as a delay or difficulty in defecation,
present for two or more weeks and sufficient to
cause significant distress to the patient.
Stool frequency of < 3 per week is also defined
as constipation

3. Rome III criteria Constipation
infants and children up to 4 yrs
 One months of at least 2 of the followings
◦ 2 or fewer defecations per week
◦ At least 1 episode per week of incontinence after acquiring
toileting skills
◦ History of excessive stool retention
◦ History of painful or hard bowel movements
◦ Presence of a large fecal mass in the rectum
◦ History of large diameter stools that may obstruct the toilet
 Accompanying symptoms
◦ Irritability, decreased appetite and / or early satiety.
◦ The accompanying symptoms disappear immediately
following passage of a large stool.

4. Classification of constipation
I. Depending upon the age of onset
Congenital constipation (Since birth)
Acquired constipation

5. Classification of constipation
II. Depending upon the duration
Acute constipation (2 weeks to 3 months)
Chronic constipation (> 3 months)
Mild - No megarectum/megacolon or impaction
- No encopresis
Severe – megarectum / megacolon or impaction
- Associated with encopresis

6. Etiology of chronic constipation
Congenital
Anorectal defects
Anal stenosis / atresia
Imperforate anus
Anterior displaced anus
Neurogenic
Myelomeningocele
Spina bifida
Colonic neuropathies
Hirschsprung’s disease
Intestinal neuronal dysplasia
Colonic defects
Colonic atresia
Short colon
Aquired
Functional 90-95%
Anal lesions
Fissures, abscesses, strictures
Neurological conditions
Cerebral palsy, MR
Lesions of spinal cord
Metabolic
Hypokalemia,hypercalcemia,
Endocrine
Hypothyroidism, DM
Hyperparathythroidism
Drug induced
Antimotility, anticholinergics
Codeine, antacids

7. What is normal ?
 Stool frequency decreases from a mean of
4/day in the first week of life to 1.7/day by the
age of 2 years
 In this period, stool volume increases 10 fold,
water content consistent approximately 75%
 Intestinal transit time from mouth to rectum
increases from 8 hours in the first month of
life to 16 hours by 2 years of age to 26 hours
by the age 10.

9. How does it work ?
 Sigmoid colon acts as storehouse of faeces
 When more than 15 cc of stool enters the normal
rectum, relaxation of internal sphincter
 Relaxation of internal sphincter allows the stool to
reach the external anal sphincter and the urge to
defecate is signaled
 If the child relaxes the external anal sphincter,
squats to straighten the anorectal canal, and
increases intra-abdominal pressure the rectum is
evacuated of stool

10. Pathogenesis
Painful defecation
Voluntary withholding
Prolonged fecal stasis
Re-absorption of fluids
 in size & consistency
More pain

11. Why it occurs ?
 Diet – low in fiber
 Unsuccessful toilet training
 Logical response to painful stools (anal inflammation
from fissures, perianal infection, perianal abscess)
 Threatening event such as a television show, birth of a
sibling
 Desire to avoid defecation in a strange toilet when away
from home.
 Some toddlers and older children are too distracted to
evacuate (mainly ADHD).

12. Red flag signs - History
 Onset < 1 year
 Delayed passage of meconium
 Absence of withholding, soiling
 Bladder dysfunction
 Non-GI symptoms
 No response to Rx

13. Red flag signs - Exam
 FTT
 Abdominal distension
 Pilonidal sinus
 Lack of lumbosacral curve
 Patulous anterior anus
 Empty rectum on PR
 Absent anal wink, cremasteric reflex
 Lower limb weakness

14. Constipation Vs Hirschsprung’s
HD Constipation
Age Since birth or within 1 to
2 months of age
Starts after 1 year of age
Soiling Unusual Common
Straining at defecation
No straining Present
Ability to pass large
bulky stool
Unusual Common
Pain and bleeding on
defecation
Unusual Present
Anal fissures Absent Present
Rectal exam
Rectum empty Full of hard stool
Barium enema
Transitional zone Dilatation from anal canal
upwards
Rectal biopsy
Ganglion cells absent
Ganglion cells present

15. Goal of therapy
Evacuation of
stool without
pain

16. Treatment
Precise,well-organized plan: to clear fecal
retention,prevent future retention &
promote regular bowel habits.
1.Disimpaction: enema or lavage solutions
2.Maintenance: prevention of re-accumulation
I. Diet
II. Toilet training
III. Laxative
3. EDUCATION of PARENTS

17. Phase I : Complete Disimpaction
 Impaction – palpate fecal mass, dilated rectum full
of hard stools on PR, X ray abdomen
 No management plan will succeed if complete
evacuation is not achieved initially
 Without disimpaction, laxatives will cause increase
in overflow incontinence, pain, bloating, acute abd
 Oral / rectal / surgical routes of disimpaction

18. Phase I : Complete
Evacuation or Disimpaction
 Oral route
– PEG soln – 1.5gm/kg/day x 3-5 days
25ml/kg/hr till clear fluid (hosp)
- Mineral oil – 15-30ml/year (max 240ml)
x 2-3 days (not for infants)
 Lactulose, senna, bisacodyl ???
Non-invasive but slower

19. Phase I : Complete
Evacuation or Disimpaction
 Rectal route
◦ Glycerin suppository (infants)
◦ Phosphate (6ml/kg/day), saline enemas x 2-5
days
◦ Avoid tap water, soap water enemas
Faster but invasive

20. Phase II : Maintenance Therapy
 Aim is to prevent impaction and allow the
distended colon to return to normal calibre
and tone.
 Laxatives
 Diet
 Behavioral modification

21. Agents Dosages Side effects
Lactulose /Lactitol
/Sorbitol /Mannitol
1-3 ml /kg/day in 2
doses
Bloating,
cramps,
diarrhea, Safe
Magnesium
hydroxide
1-3 ml /kg/ day in 2
doses of 400mg/5ml
con.
Hypermagnese
mia,
hypophosphate
mia and
secondary
Polyeythylene hypocalcemia
glycol
(PEG) 3350
1gm/kg/day in 2 doses Nausea,
vomiting, cramps
and diarrhea
Mineral oil (liquid
paraffin)
1-3 ml/kg/ day in 1-2
doses
Aspiration risk
Lipoid
pneumonia,
nausea,
palatable if
chilled
Safe

22. Laxatives
 3-24 months of therapy
 Avoid frequent weaning of laxatives
 Adjust dose individually
 Milk of magnesia, lactulose, PEG, mineral oil
 Avoid bisacodyl, senna, phenolpthalein (rescue Rx)
 Cisapride

23. Diet in the management
 Breast feeding
 Reduce constipating foods such as dairy products,
bakery products, and starches.
 Additional fiber has no value when colorectal tone is
diminished in the child who has active functional fecal
retention.
 In the second phase, when tone is being restored,
additional fiber is of great value to improve the
“efficiency” of evacuation

24. Dietary fiber
 It is a non-starch polysaccharide - can be
soluble in water or insoluble
 Insoluble fiber swells upon contact with water
and stimulates the peristalsis and increase the
transit time.
 No “DRA” for fiber in children
 Recommended daily fiber intake is
8+ age in years in gms

25. Behavioral modification
 Regular sitting on toilet, 3 times daily after
meals for 5-10mins
 Childs feet on foot rest
 Stool diary
 Reward system

26. Follow-up schedule
Monthly: till regular bowel movement is
achieved: Check stool diary,physical and rectal
examination
Laxative dose adjusted: target (1-2 soft stool/day)
3 monthly for next 2 yrs.:
Continue same dose of laxative for at-least 3
months (distended bowel to regain its function)
and then slow tapering
(Early withdrawal of laxative is the commonest
cause of recurrence )
Yearly follow-up.

27. OUTCOME
 Excellent results 45-100% for 2 months to 3 years
 Moderate improvement 20-30%
 Failure 25-35%
 30% of children continue to be constipated during
adolescence.

28. In infants …..
 Exclude organic causes like HD, HT
anorectal problems, drugs, etc
 Faulty feeding
 Do not use mineral oil stimulant laxatives
 Avoid enemas for disimpaction
 Sorbitol, lactulose are safe
 PEG is safe

29. Thank you . . .