Overview
Definition:
A constipation clean-out regimen involves the use of medications to rapidly evacuate the lower gastrointestinal tract, typically in cases of significant fecal impaction or severe constipation unresponsive to initial management.
Epidemiology:
Functional constipation is highly prevalent in pediatric populations, affecting up to 20% of children worldwide
A significant subset of these children may require inpatient clean-out for severe impaction leading to pain, overflow incontinence, or behavioral issues.
Clinical Significance:
Effective clean-out is crucial to alleviate patient discomfort, improve bowel function, prevent complications like urinary tract infections or abdominal pain, and facilitate successful long-term management of constipation
Poorly managed impaction can lead to chronic issues and significant distress.
Clinical Presentation
Symptoms:
Abdominal pain
Hard, infrequent stools
Straining during defecation
Fecal soiling or encopresis
Decreased appetite
Nausea
Vomiting (in severe cases)
Palpable fecal mass in the abdomen.
Signs:
Abdominal distension
Rectal examination may reveal hard, impacted stool in the rectal vault, sometimes with leakage of liquid stool around the impaction (overflow incontinence)
Visible fecal impaction on abdominal palpation
Poor weight gain in chronic cases.
Diagnostic Criteria:
Rome IV criteria for functional constipation are often met
Specific diagnosis of fecal impaction is typically made based on clinical history and physical examination, sometimes supported by imaging if diagnosis is uncertain.
Diagnostic Approach
History Taking:
Detailed history of bowel habits including frequency, consistency, and pain
Duration of symptoms
Diet and fluid intake
Toilet training history
Previous treatments and response
Presence of encopresis
Red flags: blood in stool, fever, weight loss, family history of GI malignancy or Hirschsprung disease.
Physical Examination:
General assessment for dehydration and distress
Abdominal examination for distension, tenderness, and palpable masses
Digital rectal examination to assess for impaction, tone, and anal fissures
Assess for neurological deficits.
Investigations:
Generally, investigations are not required for uncomplicated functional constipation and clean-out
Plain abdominal X-ray can confirm fecal loading and impaction if diagnosis is unclear or severity needs assessment
In select cases, ultrasound may be used
Routine blood tests, urine analysis are typically not indicated unless other co-morbidities are suspected.
Differential Diagnosis:
Hirschsprung disease
Intestinal obstruction (e.g., due to strictures, adhesions)
Malrotation with volvulus
Inflammatory bowel disease
Celiac disease
Hypothyroidism
Neurological conditions affecting bowel motility
Metabolic disorders (e.g., hypokalemia)
Lead poisoning.
Management
Initial Management:
Discontinue constipating medications if applicable
Provide adequate hydration and pain relief
Initiate a clean-out regimen once impaction is confirmed and the child is stable.
Medical Management:
Clean-out regimens typically involve osmotic laxatives
Common agents and typical pediatric doses for inpatient clean-out include: Polyethylene Glycol (PEG) 3350: 1.5-2.5 g/kg/day (maximum 100g/day) divided into 2-3 doses, mixed with liquid, taken over 1-3 days
Lactulose: 1-2 mL/kg/dose every 4-8 hours until evacuation, then adjusted for maintenance
Sodium phosphate enemas: Can be used for immediate rectal disimpaction but should be used cautiously due to risk of electrolyte imbalances, especially in infants
Bisacodyl suppositories or stimulant laxatives: May be used adjunctively for rectal stimulation if osmotic agents are insufficient, but long-term reliance should be avoided.
Surgical Management:
Surgery is rarely indicated for simple constipation and is reserved for specific complications like fecalomas causing obstruction not relieved by medical management, or for underlying anatomical abnormalities causing the constipation
Procedures like colonic lavage via surgery or stoma creation are exceptionally rare for clean-out purposes.
Supportive Care:
Regular monitoring of vital signs, fluid balance, and stool output
Patient and family education on the clean-out process, expected outcomes, and importance of ongoing maintenance therapy
Nutritional support to ensure adequate fluid and fiber intake
Toilet training reinforcement after successful clean-out.
Complications
Early Complications:
Abdominal cramping and bloating during clean-out
Electrolyte disturbances (especially with phosphate enemas or over-vigorous laxative use)
Anal fissures or irritation from frequent stools
Dehydration if fluid intake is inadequate
Nausea and vomiting.
Late Complications:
Recurrence of constipation and impaction if maintenance therapy is not followed
Development of avoidance behaviors related to defecation
Impact on psychosocial well-being
Chronic encopresis.
Prevention Strategies:
Strict adherence to prescribed maintenance therapy after clean-out
Adequate fluid and fiber intake
Regular toilet sitting routine
Prompt treatment of any early signs of constipation recurrence
Family education on long-term management strategies.
Prognosis
Factors Affecting Prognosis:
Adherence to maintenance therapy
Family involvement and education
Underlying causes of constipation (if any)
Age of the child
Severity and duration of impaction.
Outcomes:
With successful clean-out and appropriate maintenance therapy, most children achieve significant improvement in bowel function, relief of symptoms, and resolution of encopresis
Long-term success depends heavily on adherence to lifestyle and dietary modifications.
Follow Up:
Regular follow-up with a pediatrician or pediatric gastroenterologist is essential to monitor progress, adjust maintenance therapy as needed, and address any emerging issues
This often involves regular scheduled appointments for several months to a year post-clean-out.
Key Points
Exam Focus:
DNB/NEET SS will test knowledge of appropriate agents for pediatric clean-out (PEG 3350 is first-line)
Understand contraindications and cautions with agents like sodium phosphate
Recognize signs of impaction and when clean-out is indicated.
Clinical Pearls:
Always start with osmotic agents like PEG 3350 for pediatric clean-out
Mix PEG with palatable liquids (juice, broth) to improve tolerance
Rectal examination is crucial for assessing impaction
Education is key: empower families with the tools for long-term success.
Common Mistakes:
Over-reliance on stimulant laxatives for clean-out
Inadequate fluid intake during clean-out
Failure to establish a maintenance regimen post-clean-out
Misinterpreting encopresis as diarrhea
Not considering underlying medical causes in refractory cases.