Journal of Pediatric Surgery 53 (2018) 1742–1747

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Journal of Pediatric Surgery

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Idiopathic constipation: A challenging but manageable problem

Andrea Bischoff a,⁎, Giulia Brisighelli b, Belinda Dickie c, Jason Frischer d, Marc A. Levitt e, Alberto Peña a
a
International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
b
Fondazione IRCCS Ca’ Granda–Ospedale Maggiore Policlinico, Milan, Italy
c
Colorectal and Complex Pelvic Malformation Center, Boston Children's Hospital, Boston, MA, USA
d
Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
e
Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH, USA

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: A protocol to treat idiopathic constipation is presented.

Received 27 July 2017 Methods: A contrast enema is performed in every patient and, when indicated, patients are initially submitted to a
Received in revised form 19 September 2017 “clean out” protocol. All patients are started on a Senna-based laxative. The initial dosage is empirically deter-
Accepted 20 September 2017 mined and adjusted daily, during a one week period, based on history and abdominal radiographs, until the
amount of Senna that empties the colon is reached. The management is considered successful when patients
Key words:
empty their colon daily and stop soiling. If the laxatives dose provokes abdominal cramping, distension, and
Idiopathic constipation
Encopresis
vomiting, without producing bowel movements, patients are considered nonmanageable.
Laxative Results: From 2005 to 2012, 215 patients were treated. 121 (56%) were males. The average age was 8.2 years
Senna (range: 1–20). 160 patients (74%) presented encopresis. 67 patients (32%) needed a clean out. After one week,
Bowel management 181 patients (84%) achieved successful management, with an average Senna dose of 67 mg (range:
5–175 mg). In 34 patients (16%) the treatment was unsuccessful: 19 were nonmanageable, 3 noncompliant,
and 12 continued soiling. At a later follow-up (median: 329 days) the success rate for 174 patients was 81%.
Conclusion: We designed a successful protocol to manage idiopathic constipation. The key points are clean out
before starting laxatives, individual adjustments of laxative, and radiological monitoring of colonic emptying.
Treatment study: Level IV.
© 2017 Elsevier Inc. All rights reserved.

Idiopathic constipation is the incapacity or difficulty to pass enough Patients with idiopathic constipation frequently undergo many
stool regularly and efficiently. The cause of this condition is unknown medical consults and diagnostic exams, and they often suffer from anx-
[1,2]. It is by far the most common defecation and colonic motility disor- iety or behavioral problems related to their constipation. Laxatives, bio-
der in children, and it is a common cause for surgical consultation [1–4]. feedback, psychological treatments, electrical stimulation, Botox
Idiopathic constipation is a spectrum. Mild forms can usually be injection and enemas are frequently offered in attempt to improve
treated with dietary modifications and fiber whereas severe forms of their symptoms with variable results [7–10]. In some cases, surgical pro-
constipation and encopresis are unresponsive to standard medical ther- cedures are performed such as cecostomy tube placement, Malone pro-
apies. Extreme forms include cases with very severe symptoms that cedure or different lengths of colonic resections, both transabdominal
overlap in its manifestations with the condition known as “intestinal and transanal [11–14].
pseudobstruction” [1]. These children suffer from abdominal pain, The literature describing these different treatment options for idio-
bloating, impaction and soiling that often result in a poor quality of pathic constipation does not describe the magnitude of the patient's
life and delayed social development [1–3]. Some patients are also inca- constipation, making it very difficult to interpret their results and
pable of emptying their bladder, despite no recognizable spinal or neu- apply them to our patients. Therefore, we designed a specific bowel
rologic abnormality, and have a higher rate of enuresis and urinary tract management protocol adapted by trial and error to the magnitude of
infections [5,6]. each patient's constipation. This trial and error protocol is implemented
over a period of one week, taking daily abdominal radiograph films to
evaluate the response to treatment, and modifying the dosage of laxa-
tives accordingly.
⁎ Corresponding author at: International Center for Colorectal and Urogenital Care,
Children's Hospital Colorado, 13123 East 16th Avenue, Box 323, Anschutz Medical The salient features of our protocol are:
Campus, Aurora, CO, 80045. Tel.: +1 720 777 9448; fax: +1 720 777 7891.
E-mail address: [email protected] (A. Bischoff). - This condition is incurable but manageable.

https://doi.org/10.1016/j.jpedsurg.2017.09.022
0022-3468/© 2017 Elsevier Inc. All rights reserved.
 A. Bischoff et al. / Journal of Pediatric Surgery 53 (2018) 1742–1747 1743

- Since this disorder is a spectrum with different magnitudes of consti- enormous amount of laxative that provoked severe symptoms of abdom-
pation, every patient needs an individualized treatment regimen. inal distension, cramping, and vomiting, without producing bowel move-
- The severity of the constipation is measured by the degree of dilation ments); persistent soiling (patients who still had soiling even though we
of the colon and the amount of senna laxative necessary to empty found the laxative dose that produced a daily bowel movement and emp-
the colon on daily basis (radiologically demonstrated). tied their colon as confirmed radiologically; noncompliant (patients that
- The amount of laxative that each patient needs is different and is de- did not take the prescribed amount of Senna either for social reasons, eco-
termined by trial and error. nomic barriers, or cultural beliefs).
- Patients with extreme constipation who failed to pass stool, became In patients that were considered nonmanageable, a colonic resection
distended, and vomited after receiving laxatives 10–15 times higher was offered in attempt to reduce the amount of Senna that they needed
than the recommended dosage are considered “resistant to medical to empty their colon.
treatment” and are therefore candidates for a surgical treatment. The water soluble enemas were also reviewed and the presence of
dilation or redundancy was recorded. In order to determine if the laxa-
The first step of our protocol consists in performing a water soluble tives requirement could be predicted based on the contrast enema, we
contrast enema, without bowel preparation, to evaluate the characteris- measured the recto pelvic ratio (diameter of the rectal width divided
tics of the colon and the degree of rectosigmoid dilation. If fecal impac- by the diameter of the transverse line of the pelvis which is the greatest
tion is diagnosed, he/she undergoes a clean out protocol before starting horizontal diameter of the pelvis) (Fig. 1) and correlated it to the dose of
laxatives. The clean out protocol consists of the administration of three laxatives needed to completely empty the colon. In the literature, this
enemas per day for three days with daily radiological monitoring to ob- index has been used to provide objective and reproducible values for
jectively confirm successful emptying of the colon. The three enemas the size of the rectum [15]. Patients with a recto pelvic ratio greater
are: 1) normal saline + liquid glycerin, 2) normal saline + fleet than 0.61 were defined as having megarectum [16].
enema, 3) normal saline + castile soap. If the patient remains impacted, Student's t-test was used to compare continuous data and Fisher's
he/she is admitted to the hospital and receives Golytely® (25 ml/kg/h) exact test and chi-squared test were used to compare categorical
through a nasogastric tube for 2 days in addition to the enemas. If fecal variables.
impaction persists, as radiologically demonstrated, the patient is then IRB approval was obtained for this study (# 2012–3653).
taken to the operative room for manual disimpaction under anesthesia.
Once the colon is confirmed clean on the abdominal radiograph, the 2. Results
trial and error protocol is started with a Senna based laxative. The initial
dose is arbitrarily determined based on the magnitude of the colonic di- A total of 275 patients affected by idiopathic constipation, with age
lation as seen on contrast enema. The parents are instructed to record from 11 months to 20 years old were identified. Sixty patients were ex-
the number and consistency of bowel movements during the next cluded from the study because they did not meet the inclusion criteria
24 h. If there is no bowel movement in 24 h, the parents are instructed (Table 1). Therefore, 215 patients were included in the study. Among
to give an enema to clean out the colon, and the laxative dose is in- these patients, 121 (56%) were male and 94 (44%) female. Relevant co-
creased by 15 mg on that same day. If the patient has multiple liquid morbidities are presented in Table 2.
bowel movements, the laxative dose is decreased by 7.5 mg of Senna. The average age at presentation was 8.2 years (range 1–20), and 201
This trial and error protocol is followed during the one week period (94%) of patients were greater than 3 years old, the typical age at which
until the abdominal film shows a clean colon. The goal is to reach the children become potty trained.
point where the patient adequately empties his/her colon on daily The information about the duration of constipation symptoms was
basis with radiologic confirmation. The dosage of senna laxative re- available for 148 patients: 55 (37%) of them had constipation symptoms
quired to reach that point, is considered an objective measure of the since birth and 93 (63%) of them developed constipation after the new-
magnitude of the patient's constipation. The family is then educated born period, most commonly after the introduction of solid foods. The
that the patient must receive at least that amount of laxative daily on average duration of symptoms for patients that presented with consti-
a permanent basis to avoid fecal impaction and soiling. pation later in childhood was 54 months.

1. Material and methods 2.1. Presenting symptoms at first visit at the colorectal center

We performed a single institution retrospective review of patients 160 patients suffered from encopresis (overflow pseudoincontinence),
with idiopathic constipated patients treated with our laxative protocol, with a similar distribution between the two sexes.
from June 2005 to October 2012 at Cincinnati Children's Hospital Owing to episodes of fecal impaction 109 patients (59%) were previ-
Colorectal Center. Data about gender, age, coexistence of other medical ously admitted to the emergency room, this information being available
conditions, soiling (pre- and posttreatment), previous episodes of im- for 186 patients.
paction, fecal impaction upon presentation, laxative requirement, mag-
nitude of colonic dilation, and redundancy observed in the contrast 2.2. Treatment at the colorectal center
enema, were abstracted. Patients with incomplete medical records
and patients previously subjected to rectosigmoid resection, either by Radiographic evaluation demonstrated a normal sacrum in all pa-
our surgeons or at other facilities, before participating in the laxative tients. On water soluble contrast enema, 142 patients (66%) had a
management week were excluded from the study. Patients affected by megarectosigmoid (Fig. 2) and 19 (9%) had a generalized dilation of
conditions such as anorectal malformations, Hirschsprung’s disease, the colon (Fig. 3) (Table 3). The recto pelvic ratio was measured in
spina bifida, tethered cord, Down syndrome, thyroid anomalies, cere- 208 patients. The average value was 0.71 and 182 (88%) patients that
bral palsy, and mitochondrial anomalies were also excluded from the had a megarectum, defined as having a recto pelvic ratio greater than
study. 0.61 [16].
A laxative trial was considered successful when the daily dosage of 67 patients (32%) needed clean out with enemas prior to starting our
laxative required to empty the colon, as confirmed by a clean colon on laxative protocol. Among these patients, 8 (4%) were admitted and re-
abdominal radiograph, was reached, and the patient remained clean in ceived Golytely® through a nasogastric tube. No patients required man-
his/her underwear. ual disimpaction under anesthesia.
Patients in whom the program was unsuccessful were divided in The average daily dose of Senna administered at the beginning of the
three different categories: nonmanageable (if they required an laxative trial was 61 mg (range 15–165 mg). At the end of the week the
1744 A. Bischoff et al. / Journal of Pediatric Surgery 53 (2018) 1742–1747

Fig. 1. The arrow in the left image shows the linea transversa which is the biggest diameter of the pelvis. In the contrast enema, the biggest diameter of the rectosigmoid and the linea
transversa are marked. By dividing the biggest diameter of the rectosigmoid by the linea transversa we were able to calculate the recto pelvic ratio for every patient. In this case: 84.4/
102.0 = 0.83.

average dose was 69 mg (0–180 mg). The average dose of Senna was 2.3. Surgical procedures
not significantly different between patients with megarectosigmoid or
dilated colon throughout (68 mg vs 74 mg). Out of the 215 patients who underwent the laxative protocol, 41
The laxative requirement was directly related to the patient's age but (19%) ultimately underwent colonic resection. This group deserves a
was not related to the recto pelvic ratio (Fig. 4). separate, special discussion in a future publication.
175 patients received soluble fiber together with the laxative treat-
ment. Fiber was used to improve the consistency of the stool, when 2.3.1. Follow-up
they were too liquid from the laxative usage. Recommended fibers in- Fifty-two patients (24%) had follow-up for less than 30 days, there-
cluded Benefiber®, Citrucel®, and pectin and were prescribed at a dos- fore we considered them lost to follow-up. The patients that were lost
age varying from one to three tablespoons per day. to follow up were evenly distributed among the ones that responded
The laxative protocol was successful (clean underwear and clean to laxatives and those who did not respond. The mean follow-up for
colon on abdominal radiograph) in 181 (84%) patients out of 215. Pa- the remaining 163 patients was 329 days (range 31–2612 days). After
tients in whom the treatment was not successful were younger than the end of the week-long laxative trial, the patient's response to the lax-
those in whom it was successful (7.6 versus 8.3 years old). The rate of atives was monitored remotely with telephone and e-mail contact and
failure among developmentally delayed patients was significantly occasional abdominal films. Among patients with follow-up, 99 patients
higher if compared to nondelayed patients. The average amount of (81%) maintained successful response to laxatives. In 40 patients, it was
Senna was not significantly different in cases in whom the treatment necessary to increase the daily laxative dose from the prescribed dose at
was successful or unsuccessful (67 vs 81 mg, respectively). Moreover, the end of the laxative trial week (the increase varied from 5 mg to
the recto pelvic ratio was not significantly different between patients 93 mg of Senna). In 24 patients, the Senna dose was decreased at
that responded successfully to laxatives as compared to patients that follow-up (the decreased varied from 2.5 mg to 74 mg of Senna). 30 pa-
did not respond successfully (0.70 vs 0.71, p-value 0.66). tients continued to receive the same amount of Senna they received at
Among the patients in which the laxative protocol was considered the end of the laxative trial. For 5 patients, the information regarding
not successful (n = 34), 19 were considered nonmanageable, 12 were the amount of Senna received at follow up was not available.
still soiling despite having daily bowel movements and a clean colon
on abdominal radiographs, and 3 were not compliant. 2.4. Previous therapies and procedures
The most common side effect experienced by patients was cramping
(n = 47). This group of patients required a significantly higher amount All of our patients were taking or had taken other laxatives prior to
of senna as compared with those that did not complain of cramping our laxative trial. The most common laxative patients had taken previ-
(96 mg compared to 62 mg). Besides cramping, no other side effects ously was Polyethylene Glycol (Miralax®) (97%), followed by Senna
were observed related to the use of Senna.

Table 2
Characteristics of our series of patients and prevalence of behavioral problems and devel-
opmental delay among the patients.

Table 1 Total number of patients 215

Exclusion criteria and number of patients excluded for each criteria. Males 121 (56%)
Females 94 (44%)
Reason for exclusion No. of patients excluded
Age 8.2 y.o. (1–20 y.o.)
Incomplete medical record 29 Developmental delay 29/215 (15%)
Colonic resection before laxative protocol 17 Behavioral problem 55/215 (27%)
Down syndrome 5 Autism 12/55 (22%)
Mitochondrial disease 3 ADHD 23/55 (42%)
Hypothyroidism 2 Anxiety/depression 16/55 (29%)
Cerebral palsy 2 Other 11/55 (20%)
Spinal intervention before laxative protocol 2 Idiopathic rectal prolapse 11/223 (5%)
 A. Bischoff et al. / Journal of Pediatric Surgery 53 (2018) 1742–1747 1745

Fig. 2. The contrast enema of a patient with a dilated rectosigmoid. The two arrows show
how the size of the sigmoid colon is bigger than the size of the rest of the colon. Fig. 3. The contrast enema of a patient with a dilated colon throughout. The two arrows
show how the size of the sigmoid colon and of the rest of the colon is similar.

(41%), Milk of Magnesia® (14%), Bysacodyl® (11%), Amitza® and

Colace® (6%). The average daily dose of Miralax taken by the patients our program since our goal is to determine how much laxative the pa-
was 25 mg a day while the average daily dose of Senna taken by the pa- tients need to daily empty their colon adequately (Fig. 5). We are very
tients was 33 mg per day. In all cases the laxative dose previously given proud that with our clean out protocol, we have been able to avoid man-
was inadequate and constipation symptoms persisted. Additionally, 36 ual disimpaction under anesthesia. We also believe that the active par-
patients (19%) were regularly receiving enemas for the treatment of ticipation of the patient during the process of clean out helps them
constipation. understand the importance of following our recommendations for
Before referral to our center, 29 children (13%) underwent some long-term management of his/her constipation.
procedure. The most common procedure used for treatment of consti- With this protocol, we achieved a success rate of 84% immediately
pation was botox injections (n = 16). Additional procedures patients after the one week laxative protocol and 81% at follow-up. All of the pa-
underwent for treatment of their constipation included anal sphincter tients in whom our management was successful had previously been
myectomy (n = 5), cecostomy n = (5), and appendicostomy/MACE prescribed laxatives and failed. This emphasizes the importance
procedure (n = 4). One child underwent myectomy, botox injection adjusting laxative dosage on an individual basis and by trial and error
and MACE procedures while another child underwent 7 botox injec- with radiologic demonstration.
tions. While some of these patients had temporary improvement after An unnecessary surgical procedure was performed in 13% of our pa-
the procedure, eventually the constipation worsened in all patients. tients prior to the referral to our Colorectal Center. Botox injections may
give a temporary improvement of symptoms but eventually the symp-
3. Discussion toms persist. Therefore, we do not recommend Botox injections for
the management of idiopathic constipation. Myectomies are controver-
We believe that the vast majority of patients with severe constipa- sial procedures, frequently performed without scientific basis. We do
tion can be managed medically, with an appropriate evaluation and an not perform them. Cecostomies or operations to administer antegrade
individually designed laxative protocol as demonstrated in our series.
We believe that the diagnosis of idiopathic constipation is a clinical
one. We also found the contrast enema performed with a hydrosoluble Table 3
material to be a valuable diagnostic tool to confirm the diagnosis [1]. Features of the colon at the water soluble enema according to the presence of dilation.

Rectal dilation in the contrast enema did not predict the amount of Colonic dilation at contrast enema
laxatives needed to completely empty the colon. This finding reinforces Dilated rectum and or sigmoid 142
the importance of a trial and error approach over a one week period No or minimal dilation 42
with radiological evaluation. Dilated colon throughout 19
Clean out with enemas was needed in 30% of our patients prior to Dilated right colon 6
Total 209
initiation of the laxative protocol (Fig. 5). This represents a key step in
1746 A. Bischoff et al. / Journal of Pediatric Surgery 53 (2018) 1742–1747

Fig. 4. Chart on the left shows the relation between the age of the patient at the beginning of the laxative protocol and the dose of senna required to empty the colon at the end of the
laxative protocol. Chart on the right shows the relation between the rectopelvic ratio and the dose of senna that the patient required to empty the colon.

enemas represent an alternate route of administration of enemas. We constipation are trials to compare the effectiveness of Polyethylene
believe that most patients do not need enemas to treat constipation. Glycol® with other osmotic and stimulant laxatives; no systematic use
We highly recommend this protocolized medical management of con- of Senna had been reported in the literature [18]. In our experience
stipation prior to any invasive procedure. Enemas could be considered Senna (used with much higher doses than the ones recommended in
in the group that did not respond to our protocol, as an alternative to the literature), has revealed to be an effective and safe stimulant laxa-
an operation. tive. Other than abdominal cramping, no other side effects were report-
In the literature, we could not find any publication that describes the ed in our series. In the literature a few cases of senna-induced dermatitis
magnitude of the constipation with objective criteria other than the have been reported in the past and the carcinogenic potential of chronic
number of bowel movements per day. We believe that this is not an ob- use of senna has been extensively excluded by both retrospective and
jective method because we sometimes see patients with severe forms of prospective studies [19,20].
stool accumulation that have many “bowel movements” per day. We We believe that a long-term follow-up with continued adjustment
think that the laxative dosage is individual, not weight dependent, and of the laxative dose is crucial for a long-term success. Unfortunately,
that the dosage required to achieve a clean colon radiologically mea- 24% of the patients in our series had a follow-up shorter than
sures the magnitude of the problem. 1 month. We do not know what the reasons for lost to follow-up were.
An abdominal radiograph is the only way to prove that the colon is Some physicians prescribe laxatives for a short period of time and
empty. In our series, the dose of laxatives that the patients needed to then decrease the dose gradually until stopping the laxative based on
empty their colon was, as expected, directly related to their age. Howev- the idea that idiopathic constipation is curable [21]. We do not recom-
er many exceptions were present and we should not consider age as a mend tapering/decreasing the dose since we believe that idiopathic
predictor of laxative requirement. constipation is a chronic, not curable, disease. However, we believe
The recto pelvic index was not related to the laxatives requirement. that idiopathic constipation is a manageable condition that requires
This is probably because of the fact that it is a based on a two- long term treatment and follow-up.
dimensional measure and that it only takes into consideration the size It is clear that the overwhelming majority of patients with severe id-
of the most distal part of the rectosigmoid and not the entire colon. iopathic constipation do not need surgery. Rather, they only need an ap-
An older age and normal mental development seemed to correlate, propriate evaluation and correct medical management [4].
although not significantly, with the rate of success of our management.
This is expected because younger children and children with develop- 4. Conclusions
mental problems are more likely to be more affected by the cramping
that the laxatives can cause. Idiopathic constipation is a spectrum, and in its extreme forms, rep-
In the literature we were able to find only one publication about sys- resents a therapeutic challenge. Using a protocol based on the idea that
tematic use of Senna for childhood idiopathic constipation in a series of every patient is different and that each one requires a different quantity
21 patients [17,18]. Most of the studies published about idiopathic of laxative, it is possible to improve the results of treatment. A contrast

Fig. 5. Abdominal radiographs during a bowel management week showing: a) fecal impaction, b) successful clean out with enemas, c) abdominal radiograph on beginning of the week
showing stool in the rectum, d) abdominal radiograph in the end of the week on 60 mg of senna.
 A. Bischoff et al. / Journal of Pediatric Surgery 53 (2018) 1742–1747 1747

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