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Management of the child with refractory constipation
Julia M J van der Zande1,2, Peter L Lu1
1Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA.
Insights
Recent advances in treating pediatric refractory constipation offer new hope. New diagnostic tools and treatments like linaclotide and transanal irrigation can improve outcomes for children with difficult-to-manage constipation.
Area of Science:
- Pediatric Gastroenterology
- Colorectal Surgery
- Pediatric Surgery
Background:
- Pediatric refractory constipation presents significant management challenges.
- Current management practices for this condition are highly variable.
- There is a need for updated guidelines and treatment algorithms.
Purpose of the Study:
- To review recent advancements in evaluating and treating pediatric refractory constipation.
- To propose a management algorithm integrating the latest evidence and clinical experience.
- To provide clinicians with an updated approach to complex pediatric constipation cases.
Main Methods:
- Comprehensive literature review on diagnostic tests for refractory constipation in children.
- Review of emerging and established treatment options for pediatric refractory constipation.
- Synthesis of evidence to inform a clinical management algorithm.
Main Results:
- Advanced diagnostics like anorectal and colonic manometry aid in identifying underlying disorders.
- Newer pharmacologic options (e.g., linaclotide) and interventions (e.g., transanal irrigation, botulinum toxin injections) show promise.
- Surgical options including antegrade continence enemas, colonic diversion, and resection are reserved for severe, refractory cases.
Conclusions:
- Recent therapeutic and diagnostic innovations provide improved options for children with refractory constipation.
- An evidence-based algorithm can guide the multidisciplinary management of these complex pediatric cases.
- Further research is ongoing to refine treatment strategies for pediatric refractory constipation.
Background:
Caring for children with constipation refractory to conventional treatment can be challenging and management practices vary widely.
Aims:
To review recent advances in the evaluation and treatment of children with refractory constipation and to propose an algorithm that incorporates the latest evidence and our institutional experience.
Methods:
We performed a literature review on diagnostic tests and treatment options for children with refractory constipation.
Results:
Evaluation of a child with refractory constipation seeks to better understand factors contributing to an individual child's presentation. Anorectal manometry evaluating for a rectal evacuation disorder and colonic manometry evaluating for colonic dysmotility can guide subsequent treatment. For the child who has not responded to conventional treatment, a trial of newer medications like linaclotide can be helpful. Transanal irrigation offers a safe and effective alternative for families able to administer daily rectal treatment. Despite mixed evidence in children, pelvic floor biofeedback therapy can help some children with pelvic floor dyssynergia. For younger children unable to cooperate with pelvic floor therapy, or older children with refractory symptoms, internal anal sphincter botulinum toxin injection can be beneficial. Antegrade continence enema treatment can be effective for children with either normal colonic motility or segmental dysmotility. Sacral nerve stimulation is generally reserved for symptoms that persist despite antegrade continence enemas, particularly if faecal incontinence is prominent. In more severe cases, temporary or permanent colonic diversion and segmental colonic resection may be needed.
Conclusions:
Recent advances offer hope for children with refractory constipation.
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