Chronic constipation is a major problem in the general community, but is not commonly discussed and its prevalence is underestimated. Common constipation is when a child has hard faeces (stool) or does not go regularly. There is a lot of difference in the firmness and frequency of stool in normal children. Constipation is quite a common problem in children, but with improvement in bowel habits and appropriate use of medications, it can usually be controlled.
However, there is a subgroup of children that present with slow transit constipation (STC), that have a functional abnormality because of disordered nerves and muscles of the colon itself. Many children with STC have been found by biopsy to have abnormalities of the neurotransmitters (messenger molecules in the nerves) in the muscular layers of the bowel wall. In particular, they have a deficiency of Substance P, a peptide thought to be involved in the activation of bowel contraction. In these children, movement of stool within the colon is markedly delayed. In kids with STC the stool often remains stored in the right or middle portion of the colon and does not progress adequately to the rectosigmoid colon, causing a build up and discomfort. It is the rectosigmoid colon that is responsible for the propulsion and transfer of stool (poo) out of the body.
The symptoms of STC include long delays in the passage of stool, accompanied by lack of urgency to move the bowels. It has been determined that the normal frequency of stool passage is three or more bowel movements per week, however in children with STC often they do not pass a stool for 7-10 days at a time; at times longer. Physically, many children with STC do not appear unwell. Sometimes this can lead to inaccurate perception that their health problems are not significant. These children and their families can face considerable difficulties, with distressing symptoms and never-ending treatments.
Many children who have been diagnosed with STC (and some other children with difficult to manage constipation and soiling) continue to have symptoms even with the best treatment available at present. They may have nausea, abdominal pain, poor appetite and soiling. They often have had symptoms for some time and many frustrations associated with their poor response to treatments. They may have had unpleasant treatment regimes. The management may have involved uncomfortable and potentially frightening procedures, including repeated enemas. Treatments will often have included large doses of laxatives orally or by naso-gastric tube and many children will have had multiple hospital admissions for these treatments.
Despite the best efforts of health care providers and families, these children may feel different, depressed, angry and sometimes isolated and rejected. Their self esteem is often low. Some children have abdominal surgery, which can improve their physical symptoms but may exacerbate their feelings of difference. Children and young people need time to adjust to stomas or appliances and often feel self-conscious about their surgical incisions or scars. The incidence of behavioural and emotional problems in studies of children with constipation/soiling is high.
There is no need for a routine abdominal X-ray to diagnose constipation. A potentially more helpful test is a transit study. This can be done with radio opaque markers and standard X-ray or in nuclear medicine with a radio labelled drink. The test measures movement of faeces through the bowel. It can distinguish general colonic slowness (STC) from functional faecal retention in the rectum only.
Research reveals to date that one in 3000 infants and adults, of any gender, are diagnosed with STC. The condition has a genetic predisposition.
Signs and Symptoms
STC can affect young infants from birth, resulting in delay of the first stool (black meconium). Symptoms include constipation, nausea, bloating of the stomach, lack of appetite, bad breath and abnormal sleeping patterns. The child can develop faecal soiling which can interfere with parenting and infants’ welfare. Pressure from the full bowel can also cause incontinence of the bladder, often causing a confusing initial diagnosis of the condition.
Treatments, including role of specialists, effects of treatments, use of devices, daily routines
STC is a chronic condition for which there is currently no cure. Patients diagnosed with this condition may undergo various treatments to assist in making their lives more comfortable. Laxatives may offer temporary relief for some of the children; however their effectiveness can be limited. Dietary manipulation is usually ineffective. High fibre may contribute to a worsening of symptoms for these children. Other treatments include nasogastric washouts, high doses of laxatives, and enemas. Surgery may be offered when standard medical therapies have failed.
An appendicostomy (stoma) is a small opening in the abdomen wall, which leads to the caecum (large bowel). A tube is usually inserted through the appendicostomy (Chait button) with a small port which is covered by a cap. The child’s colon can then be directly accessed for bowel washouts two to three times a week. This form of treatment allows families to give the washouts at home, reducing stress and keeping hospital visits to a minimum.
Interferential therapy is painless electrical stimulation performed by a physiotherapist. It stimulates the nerve supply of the bowel, and may assist in the reduction of constipation and incontinence. This treatment is typically performed three times per week for a four-week period.