Constipation – why is it so hard? All puns intended.
Surely constipation is just passing a hard poo, what can be so difficult about that?
Personally, I would like to rename this condition so that it can gain the respect I believe it needs. Then perhaps we could have a more serious approach to its management. It is, after all, a hard condition to treat. But the good news is, with careful attention it is treatable, the results and sometimes unexpected positive outcomes, can be remarkable!
In naming this condition I have thought of various terms such as; colon dysfunction syndrome, gastrointestinal amotile disorder, or bowel dysmotilia to name a few that rattle around in my head. However, it was far more entertaining to look at slang terms for constipation, many of which made me smile; sticktus rectus syndrome, confusipated, faecally challenged, or another of my favourites, bipolar poop disorder. The latter term describing the fact that sometimes with severe constipation you can go from passing explosive stools to rabbit pellets.
I see children with constipation frequently, and over my time in practice, I seem to see it more often. I am sure this is a combination of our current diet and reduced activity that predisposes to our stuck colon syndrome, perhaps sprinkled with a little reduced attention. Sound like a lot of our lifestyle diseases (or lifestyle induced conditions)?
Whatever the causes, it is difficult to treat, not to mention frustrating, and at times a never-ending source of conflict between parent and child.
How does it present in children?
Sometimes constipation presents obviously with difficulty passing a bowel motion or abdominal pain. Occasionally the appearance of blood when pooping can let us know the degree of distress stooling has taken, we pay respect and seek advice at those times.
However, it can also present with a return of bed-wetting after being dry previously, daytime urinary accidents, recurrent urinary tract infections, skid marks in the underwear, inattention or irritability to name a few. This is why I always ask about bowel habit whenever I see a young child, as it may not be the first thing mentioned regarding the issue I am asked to review, but could be contributing.
How do I diagnose it?
That may sound easy, but many times parents have not seen their child’s bowel motions once they become toilet trained. Let’s face it, do you really want to see it after years of cleaning up stinky nappies? So yes, I start with taking the history, but usually I need to ask for a stool diary, to really see what is happening, how often and what time of the day. Many times, this is a revelation to the child and parent as well as helpful to me in making a management plan.
Should an x-ray be done?
This is not a straightforward question to answer, as an x-ray of the abdomen will not diagnose constipation on its own. It can help if there is real difficulty in getting to the bottom of the problem, or to check that a previously fully loaded bowel has been cleared out after treatment when there have been issues before. But most times an x-ray is not needed.
If an x-ray is done, it is better if I see the actual film rather than the report. A picture tells a better story and I can show you how things are looking in your child’s bowel at that time. Bear in mind if they have for some reason managed to pass a stool prior to the exam, the x-ray may be clear and therefore unhelpful.
Are there other tests that should be done?
Usually this is a functional condition, in other words, how the bowel has learned to function (or as I would say, dysfunction). So, most of the time, no, there is no need for extensive blood work or other more invasive investigations, so long as a good history and examination has been performed.
If the situation is chronic (and that means going on for a very long time), then there may be the need to ensure that there is no sign of coeliac disease or thyroid issues. Of course, gluten should remain in the diet until this has been sorted out as removing it without careful thought can make diagnosis/management complicated.
How is it treated?
Well that all depends on the severity of the constipation and how long it has been present for. Many times, we have no idea how long this has been a problem.
As in all things, I prefer to start with the diet and environmental changes first. So that is increasing fruit, vegetables, fibre and water into the diet. I like the help of a dietitian here, as is not that easy at times. Increasing fibre without increasing water can be akin to adding concrete to the concrete mixer, so a true dietary record is needed to really begin to address this. Increasing exercise is also good to help the bowels move as well as the child.
After that, then perhaps the addition of some medication to make the stool softer may be needed. If the problem is long term or had caused a number of other follow-on effects such as urine infections or urinary accidents, then a bowel washout may be needed. These days a washout is normally done at home.
Many times, when I see families, a washout has been tried with varying degrees of success. Though the process of bowel washout can be tricky, the key in successful management is what is done next. This is the bowel re-training, which is the hardest to do, requires a lot of parental supervision (yep back to the stool gazing no matter what age), and takes several months to complete. After that time if the bowel habit is settled, then withdrawal of medication can begin, but the dietary and exercise changes should continue.
If the constipation has been there for some years, then a behavioural component to its development has almost always been a part of this. That is not to say it is the child’s fault, it isn’t, they need to learn about what a good bowel habit is just like they need to learn to brush their teeth. It can be overlooked when the family’s life is busy, when the child doesn’t know that things are not working as they should, and when you as the parent really don’t want to deal with poo now that the child is toilet trained. All of this is a perfect set up for behavioural change, better known as the development of a bad habit. And we all know how hard habits are to break.
So, in summary?
Constipation is hard. Sometimes we need help to work it out.