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Management of functional constipation in children and adults

Nature Reviews Gastroenterology & Hepatology volume 17, pages 21–39 (2020)Cite this article

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Abstract

Functional constipation is common in children and adults worldwide. Functional constipation shows similarities in children and adults, but important differences also exist regarding epidemiology, symptomatology, pathophysiology, diagnostic workup and therapeutic management. In children, the approach focuses on the behavioural nature of the disorder and the initial therapeutic steps involve toilet training and laxatives. In adults, management focuses on excluding an underlying cause and differentiating between different subtypes of functional constipation — normal transit, slow transit or an evacuation disorder — which has important therapeutic consequences. Treatment of adult functional constipation involves lifestyle interventions, pelvic floor interventions (in the presence of a rectal evacuation disorder) and pharmacological therapy. When conventional treatments fail, children and adults are considered to have intractable functional constipation, a troublesome and distressing condition. Intractable constipation is managed with a stepwise approach and in rare cases requires surgical interventions such as antegrade continence enemas in children or colectomy procedures for adults. New drugs, including prokinetic and prosecretory agents, and surgical strategies, such as sacral nerve stimulation, have the potential to improve the management of children and adults with intractable functional constipation.

Key points

  • Diagnosis of functional constipation is based on a thorough medical history and physical examination; additional testing is only indicated if alarm symptoms are present or conventional strategies fail.

  • Functional constipation can be caused by lifestyle factors, psychological factors and behavioural factors; withholding behaviour is a key factor in the pathophysiology of childhood functional constipation, whereas adults often have dyssynergic defaecation patterns.

  • In adults, additional testing is used to differentiate between different subtypes of functional constipation (normal transit, slow transit and evacuation disorders) as such information has important therapeutic consequences.

  • Patients with intractable constipation should be referred to a gastroenterologist for further management; tests such as colonic transit time, anorectal manometry and a balloon expulsion test (in adults) might provide useful information.

  • Surgery is a therapy of last resort; to date, no clear guidelines exist on the surgical management of functional constipation and procedures vary widely between children and adults.

  • Future comparative randomized clinical trials are needed to further clarify the role of newer (prokinetic and prosecretory) pharmacological agents for the management of paediatric and adult functional constipation.

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Fig. 1: Pathophysiological factors of functional constipation in adults and children.
Fig. 2: Algorithm for initial presentation of symptoms of constipation.
Fig. 3: Algorithm for children referred to a paediatric gastroenterologist with chronic functional constipation.
Fig. 4: Algorithm for adults referred to a gastroenterologist with chronic functional constipation.
Fig. 5: Different methods of neuromodulation for functional constipation.

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Authors and Affiliations

  1. Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands

    Mana H. Vriesman, Ilan J. N. Koppen & Marc A. Benninga

  2. C.E.N.T.E.R. Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA

    Michael Camilleri

  3. Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children’s Hospital, Columbus, OH, USA

    Carlo Di Lorenzo

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  1. Mana H. Vriesman
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  4. Carlo Di Lorenzo
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M.H.V. researched data for the article. All authors were involved in the writing and review/editing of the manuscript before submission.

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M.A.B is a consultant for Shire, Norgine, Coloplast, Danone, Takeda, Allergan, FrieslandCampina, and Novalac. The remaining authors declare no competing interests.

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Nature Reviews Gastroenterology & Hepatology thanks O. Borrelli, A. Malcolm, G. Chiarioni and the other, anonymous, reviewers for their contribution to the peer review of this work.

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Vriesman, M.H., Koppen, I.J.N., Camilleri, M. et al. Management of functional constipation in children and adults. Nat Rev Gastroenterol Hepatol 17, 21–39 (2020). https://doi.org/10.1038/s41575-019-0222-y

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