What is chronic intractable constipation?

Related links:

• Our services: Caring for children with chronic intractable constipation

Related tests and treatments:

• Biofeedback
• Cognitive behavior therapy
• Manometry
• Sitzmark colon transit test
• Radioisotope transit study
• Surgery
• Cecostomy
• Sacral neuromodulation

About chronic intractable constipation

This broad term describes a disorder where constipation symptoms do not respond to standard laxative therapy, dietary and lifestyle changes. Children usually have history of infrequent bowel movements, passing hard stools, abdominal distension and pain for months or years. This is different from more typical childhood constipation caused by diet or lifestyle issues, and thus this condition often requires more aggressive management than typical constipation.

What causes chronic intractable constipation?

Sometimes the problem stems from abnormally slow movement of food and stool inside the bowel (slow transit constipation) or poor coordination of stool expulsion effort (dyssynergia). Chronic intractable constipation can also be associated with conditions such as Hirshsprung’s disease or anorectal malformations.

How often does chronic intractable constipation occur?

Although occasional constipation can affect any child, chronic intractable constipation is more unusual. Hirschsprung’s disease and anorectal malformations, two conditions which might cause chronic intractable constipation, each occur in 1 in 5,000 births.

How does chronic intractable constipation develop?

This problem often begins at birth but can also develop later.

What are the symptoms of chronic intractable constipation?

Children who are constipated usually have two or fewer bowel movements per week and often position their bodies differently — like arching their back, holding onto furniture or squeezing their buttocks together — to avoid having a bowel movement.

Other symptoms include:

• Difficulty passing a bowel movement
• Pain during bowel movements
• Bloating/abdominal distention
• Abdominal pain
• Soiling underwear

Who is at risk of developing this condition?

Some patients may have an abnormality of the nerve and muscle lining of the bowel. Children with certain genetic syndromes, anorectal malformations, or a hereditary GI disorder such as Hirshsprung’s disease are at risk of developing chronic intractable constipation.

Why is chronic intractable constipation a concern?

This condition often leads to severe pain. The buildup of stool can cause severe swelling and can increase the diameter of the colon to the point where it stops moving. Uncontrollable soiling can also have a severe social impact for children and teens. Chronic constipation and fecal incontinence has a significant impact on the child’s and family’s quality of life.

How is chronic intractable constipation diagnosed/evaluated?

After obtaining a medical history and conducting a physical exam, your child’s doctor might use a Sitzmark colon transit test to evaluate the bowel function. This test involves ingesting a capsule that contains tiny plastic markers and then taking X-rays to see how the markers move through the bowel. If that test indicates a problem (the markers remain in the colon instead of passing), the next step would be anorectal manometry and colon manometry, which measure the strength and coordination of muscles used to push the stool inside the bowel and coordination of bowel expulsion effort.

What is the treatment for chronic intractable constipation?

Treatment usually begins with laxatives and stimulant medications to avoid the buildup of stool and soiling that can occur as a result of chronic constipation. The doctor will also work with your child and family to identify reasons for potential stool withholding and strategies that can be used to improve defecation. Because chronic intractable constipation can be a very stressful and emotional issue, we often refer patients to psychologists for cognitive behavior therapy and biofeedback, both of which can be immensely helpful in reestablishing healthy bowel habits. Biofeedback can be particularly helpful for patients who have poor coordination of the pelvic floor muscles.

In severe cases in which conventional treatment is ineffective, your child’s doctor might recommend a cecostomy tube, which is surgically placed in the abdomen and then used to flush out the colon daily. A newer treatment used to treat chronic constipation and stool incontinence is called sacral neuromodulation.

What happens after treatment?

Many patients do very well, though some might require long-term treatment. We follow our patients as long as necessary. Once symptoms are under control, children no longer require a GI specialist’s care and can be managed by a primary care doctor.

When should you contact a physician?

If your child’s constipation is not improved by conventional treatments — such as increasing dietary fiber, water intake and exercise — talk to your pediatrician. He or she might refer you to a GI specialist for further evaluation.

What is the long-term outlook for chronic intractable constipation?

If treated early and accurately and early, children tend to do well and have minimal consequences on their life.

How do I live with chronic intractable constipation?

Although it’s not always easy to make lifestyle changes, we appreciate patients’ compliance with treatment requirements, and typically children who adhere to their treatment plan succeed in improving their symptoms and quality of life.