Bowel management is a strategy and philosophy that patients should be able to determine the timing and frequency of their bowel movements, even if they lack the anatomic or physiologic mechanism usually associated with stool control. Social continence is achieved using GI agents such as laxatives, stool softeners, or enemas to alter the timing, frequency, and consistency of the stool. A Cecostomy tube is used to flush the entire colon of stool in patients who otherwise cannot achieve adequate predictable bowel movements. We use the Chait Trapdoor Cecostomy which we feel offers better quality of life than the original Malone Antegrade Cecal Enema (MACE procedure). Surgery is reserved for patients that have failed medical treatment.
The first step in bowel management is to understand the baseline problem, exclude treatable causes of the constipation, and exclude asymptomatic patients. The last point is important because families may not understand the high degree of variability to the normal stooling pattern. The workup is usually done by a Board Certified Pediatric Gastroenterologist (Peds GI specialist). With the help of gastroenterologists or physicians specializing in children with special needs, bowel management may be accomplished without surgery. In patients who cannot achieve predictable bowel movements with medical management, cecostomy tube irrigations may offer a life free from diapers or social isolation.
Bowel management programs are used to help children with severe stooling problems which have failed diet management alone. These problems generally fall into 3 categories with different treatment strategies:
Categories and treatment strategies:
- Constipation with incontinence
- Colonic enemas alone
- No laxatives
- Regular diet
- Incontinence and increased motility
- Constipating diet
- Loperamide (Imodium AD™, others)
- Colonic irrigations
- Constipation without incontinence
- Diet modification
- Define problem (exclude treatable causes and asymptomatic patients)
- Stool softeners
- Pseudo- or overflow incontinence (Dry, retained stool with liquid stool coming around a stool impaction):
- Diagnosis with barium enema
- Treat any anatomic problems (megarectum, imperforate anus, etc)
- Colonic cleanouts as needed
- Treat constipation with diet modification, enemas, or laxatives if needed
- Routine use of bowel regimen if needed.
Anatomic factors determining continence:
- Colonic motility
- Intermittent evacuation of stool form the rectum
- Retention of rectal contents between defecations
- Internal anal sphincter
- External anal sphincter
- Puborectalis muscle and anorectal angle
- Sensory receptors (located just above the dentate line)
- Brain function
Causes of constipation:
- Abnormal stool consistency
- Anal stenosis
- Stool retention secondary to pain (anal fissures, or perirectal abscess)
- Nerve damage (spinal cord injury, meningomyelocele, Cerebral Palsy)
- Motility disorder
- Opiate use
- Endocrinologic disorders (hypothyroidism, electrolyte imbalances)
- Functional constipation
- Hirschsprung disease (1 in 4000 births)
Common diagnosis benefiting from bowel management:
- Spinal cord injury
- Imperforate anus
- Hirschsprung disease
- Sacral nerve damage
Types of Laxatives/Treatment agents:
- Bulk-producing agents
- Stool softeners / Surfactants
- Lubricants / Emollient
- Hydrating agents (osmotics)
- Hyperosmotic agents
- Stimulant / Irritant (e.g. Castor oil)
- Serotonin agonist
- Stool Softeners (Colace, polyethylene glycol (PEG) [Miralax™])
- Bulking agents (fiber, etc)
- Laxatives (magnesium)
- Retention enemas (Fleet enema)
- Colonic enemas (Saline, others)
- Combination programs
- Appendicostomy (for intermittent catheterization)
- Cecostomy tube placement (Chait Trapdoor™)
- Colostomy (rare)
Children with Constipation or Low Motility
In some children, motility of the colon is significantly reduced. Bowel management for these children consists of a program to teach the parents tor child a method to evacuate the child’s colon daily. This may include use of a suppositories, enemas or colonic irrigations. No specific diet or medication is required for these children, but the challenge is determining the right enema combination which empties the colon completely. Unfortunately, this requires trial and error. Soiling episodes or “accidents” occur when the program does not achieve complete cleaning of the bowel.
ACE Procedure – Antegrade cecostomy enemas.
Anal Fissure – An anal fissure is a small tear of the anal canal, usually caused by passage of a hard stool. Common in infants ages 6 to 24 months, anal fissures are less likely to develop in older children.
Anterior ectopic anus – An anus which is located anterior to the sphincter muscle complex. The opening is sometimes smaller than expected. It is often associated with severe intrinsic constipation despite surgical anoplasty.
Appendicostomy – The appendix is permanently brought to the skin. A small, soft plastic tube is placed into the opening to allow the colon to be completely cleaned.
Bulking agents treat constipation by increasing the volume of stool and making it easier to pass. Regular use of bulking agents is safe and often the first line of treatment for constipation.
Cecostomy tube – A small tube placed into the first part of the colon (cecum) to wash out the colon contents.
Citrucel – a brand of bulking agent.
Colace™ – Docusate sodium. A stool softener. Increases the water absorption of the stool and makes the stool softer and easier to pass. Usually takes several days to have an effect.
Colostomy – a portion of the colon brought through the abdomen and skin. This is usually used to divert stool from the rectum. Colostomies are usually covered with a special appliance (colostomy bag) to colect the stool.
Constipation – Difficult, incomplete, or infrequent evacuation of dry hardened feces from the bowels.
Docusate – A stool softener. Brand name is Colace™.
Ganglioneuroma – A benign tumor of neural origin. It may arise anywhere that neural crest cells are found. This is the benign version of neuroblastoma. Tumors damaging the sacral nerves may lead to incontinence.
Hirschsprung Disease – Congenital aganglionosis. This is a congenital disorder associated with stooling difficulties since birth. These patients lack the specialized nerve cells in the bowel wall called “ganglion” cells in the last part of the colon. Treatment is removal of the effected bowel and pullthrough of good bowel in its place.
Imperforate Anus – any of the spectrum of congenital disorders in which a male or female child is born with an absent, covered, mislocated, or fistulized anus. The anus should normally be patent and located within the muscle sphincter complex. Term newborn’s opening is typically 10 to 12 Hagar.
Golytely™ – PEG solution taken by mouth or feeding tube to clean out the colon.
Laxative – n. a food or drug that stimulates evacuation of the bowels. adj. causing looseness or relaxation, especially of the bowels. Laxatives increase the frequency of stooling. Laxatives are contraindicated (should never be taken) in patients with a suspected bowel obstruction.
Meningomyelocele – Protrusion of the spinal membranes and spinal cord through a defect in the vertebral column.
Metamucil™ – A brand of psyllium. Metamucil™ is a Bulking agents (similar to bran cereal).
Milk of Magnesia™ – a brand of laxative.
Miralax™ – A polyethylene glycol (PEG) powder which dissolves in water or other drinks. PEG is not absorbed from the intestinal tract. It stays within the gut and acts to pull water into the intestine thereby increasing the volume and frequency of bowel movements. Its effects are dose dependent.
Obstipation – Failure to pass stool due to obstruction.
PEG – Polyethylene glycol (see Miralax™).
Pena, Alberto, MD – World-recognized expert on imperforate anus. Refined and taught the posterior sagital approach to anorectal anomalies. Developed the total urogenital mobilization for the repair of cloacal anomalies. He continues to teach pediatric surgeons the optimal way to manage imperforate anus. www.cincinnatichildrens.org/svc/alpha/c/colorectal/meet-team/colorectal-surgery/alberto-pena.htm
Pena Procedure – Posterior sagital anorectoplasty as taught by Dr Pena (Dr Pena does not refer to this as the “Pena procedure,” but the rest of the world does!)
Social Continence – Having a predictable bowel patterns which allow the person to function without fear of soiling. The ability to only evacuate stool at socially appropriate times.
Spina Bifida: A congenital defect in which the spinal column is not completely closed. As a result, part of the meninges or spinal cord protrudes, often resulting in hydrocephalus and other neurological disorders.
Stool Softener – An agent which softens the stool without necessarily increasing the frequency of stooling.
Tethered Cord – A congenital anomaly in which the spinal cord has tissue attachments that limit the movement of the spinal cord within the spinal column. These attachments cause a stretching which results in spinal cord damage.
A. Pena, M Levitt “Imperforate Anus and Cloacal Malformations”
In Ashcraft, Holcomb, and Murphy (eds): Pediatric Surgery, 4th ed. Elsevier/Saunders, 2005, p. 515-16.
P. G. Chait, B. Shandling, H. F. Richards “The Cecostomy Button”
Journal of Pediatric Surgery, 32 (1997), 849-851.