Constipation of functional origin in children (view through the prism of the Rome Consensus IV)

Medical reference books

Constipation

ICD-10: K59.0

Definition Constipation is a syndrome that characterizes a violation of the process of bowel movement (defecation): an increase in the intervals between acts of bowel movement, compared with the individual physiological norm (normally, the frequency of bowel movements in a person ranges from 3 times a day to 3 times a week) or systematic insufficient bowel movement . Constipation is also considered difficulty in defecation while maintaining normal bowel movements. According to the Rome III criteria (2006), functional constipation is a functional disorder of the intestine, which is a persistent difficult, infrequent and incomplete bowel movement that does not meet the criteria for IBS. For functional constipation, bowel movement is assessed using the Bristol Stool Form Scale.

Epidemiology Constipation occurs in 30-50% of the adult population. Constipation is more common in women than in men. In recent years, there has been an increase in the frequency of constipation among rural residents (previously, constipation was typical for the urban population).

Etiology The causes of constipation are varied. The main ones are: - anomalies in the development of the large intestine (Hirschsprung's disease, etc.); — diseases of the rectum (rectal prolapse, paraproctitis, hemorrhoids, fistulas, narrowing, cracks, tumor); - colon tumors; - peptic ulcer; - cholecystitis; - appendicitis; — IBS with constipation; — physical inactivity; — diseases of the nervous system (multiple sclerosis, paraplegia, psychogenic constipation, damage to the pelvic nerve plexuses); — diseases of the endocrine system (hypothyroidism, diabetes mellitus); - severe somatic pathology (heart failure, emphysema, portal hypertension with ascites); - metabolic disorders (hypokalemia, hypercalcemia); - taking medications that inhibit the motor activity of the colon: narcotic analgesics, non-steroidal anti-inflammatory drugs, antacids containing aluminum or calcium, antidepressants (amitriptyline, etc.), anticholinergics (atropine, scopolamine), antiepileptics, antihypertensives (calcium channel blockers), sedatives, antiparkinsonian, bismuth-containing, caffeine-containing drugs, iron supplements, cholestyramine, diuretics, monoamine oxidase inhibitors, antipsychotics. There are idiopathic constipation, the cause of which is unknown. There are also so-called episodic constipation (occurs over a certain short period of time if a person has a predisposition to constipation) - constipation in tourists, during pregnancy, caused by the consumption of certain products (tea, cocoa, products with a low content of ballast substances, reduced content in the diet fluids, etc.) caused by emotional factors (depression). But such constipation, as a rule, is not considered a disease.

Pathogenesis There are several mechanisms for the development of constipation: - a decrease in the water content in the feces, with a corresponding decrease in its volume (due to a decrease in water consumption or an increase in its excretion by the kidneys, as well as a reduction in the volume of food consumed or a decrease in the content of dietary fiber in food); - difficulty in moving feces through the colon due to the presence of a mechanical obstruction (abdominal adhesions, intussusception, closure of the intestinal lumen from the inside with tumors, polyps, fecal and gallstones, paraproctitis, anorectal defects (atresia, stenosis), congenital or acquired enlargements/elongations of the colon intestines, mechanical compression of the intestines by ovarian cysts, uterine fibroids in women); - changes in the mechanisms of regulation of intestinal motility and disruption of viscero-visceral reflexes (impaired coordination of the functions of the sympathetic and parasympathetic nervous system leads to an imbalance in the system of gastrointestinal hormones that stimulate and slow down intestinal motility, as well as to changes in the sensitivity of the receptor apparatus of the colon to various stimuli and, as a result, , to hypokinetic (a decrease in the functional activity of muscles and a weakening of the tone of the intestinal wall leads to a slowdown in transit, additional absorption of water occurs, the volume of feces decreases and its density increases) or hyperkinetic (increased tone of the intestinal wall, spasm of the physiological sphincters of the intestine, weakening of propulsive motility, increased retrograde bowel movements) intestinal dyskinesia. Psychogenic constipation occurs in various stressful situations, etc., due to changes in the psychogenic reaction to the need to defecate. Conditioned reflex constipation occurs as a violation of conditioned reflexes developed (usually from childhood); - inflammation of the intestinal wall (inflammatory bowel diseases, chronic colitis, diverticulitis, etc.) leads to damage to the submucosal plexuses and rectal receptors, with a decrease in the sensitivity of the latter, an excessive increase in the tone of the anal sphincter and weakening of the pelvic floor muscles. This creates a vicious circle, since the inflammatory process in the colon causes constipation, and fecal retention maintains the inflammatory process in the intestines; - inflammatory changes in the abdominal organs (cystitis, prostatitis, metritis, parametritis, etc.), leading to spasm of the rectal sphincter or weakening of the sensitivity of its nerve endings and, as a consequence, to retention of feces in the rectum; - a decrease in the level of thyroid hormones in the body with the development of hypothyroidism, as well as loss of ovarian function due to their extirpation or radiotherapy leads to the occurrence of “endocrine constipation”; - severe diseases of internal organs (heart failure, pulmonary emphysema, portal hypertension with ascites) lead to weakening of the muscle tone of the diaphragm and anterior abdominal wall, disruption of general and abdominal circulation, which reduces the ability to increase intra-abdominal pressure during defecation, and associated metabolic disorders (hypokalemia, hypercalcemia) lead to a decrease or increase in intestinal tone; - toxic effects: poisoning with lead, benzene, nitrobenzene, sublimate, as well as when taking medications that inhibit the motor activity of the colon with the development of hypokinetic dyskinesia (including as a result of prolonged abuse of laxatives). In older people, constipation often occurs due to physical inactivity and poor nutrition. During pregnancy, constipation is associated with increased production of progesterone, and later - with compression of the sigmoid colon by an enlarged uterus.

Classification

ICD-10: K 59.0 – Constipation. There are functional constipation (there is no mechanical obstacle to the movement of contents through the intestines) and organic (impaired bowel movements are associated with the presence of a mechanical obstacle to the movement of contents through the intestines). Functional constipation (Rome III criteria, 2006) is a functional disorder of the intestine, which is a persistent difficulty in infrequent and incomplete bowel movement that does not meet the criteria for IBS: - straining, hard or compacted stools, unproductive urges, rare stools or incomplete evacuation; - less than 3 bowel movements per week, daily stool weight less than 35 g per day or straining more than 25% of the time; - elongated bowel or prolongation of colonic transit time. Depending on the time of existence, there are acute (sudden absence of stool for several days), chronic (the main symptoms are observed for more than three months out of the last 12) and episodic (the main symptoms are observed for less than three months out of the last 12). ).

Diagnostics

Complaints Most patients suffering from chronic constipation are characterized by suspiciousness and increased emotional excitability (the so-called “sickness”). The clinical picture of constipation largely depends on its cause, duration, severity and characteristics of intestinal damage. In acute constipation, there is a lack of stool for several days and no passing of gas. In inflammatory bowel diseases, constipation is usually preceded by abdominal pain of varying severity. In pathological processes of the anorectal area (anal fissures, hemorrhoids), bleeding and pain during defecation are often observed. Common symptoms may include: - nausea; - unpleasant taste in the mouth; - loss of appetite; - bloating, which, in addition to the intestinal symptoms themselves, may be accompanied by reflex reactions of other organs: pain in the heart, palpitations, etc.; — lethargy, increased fatigue; - headache; - insomnia; - unproductive urge to defecate; - daily stool weight is less than 35 g per day. Some patients may experience so-called “constipative diarrhea,” when, with a long delay in bowel movement, the stool becomes diluted with mucus, which is formed due to irritation of the intestinal wall. Also, a diagnosis of chronic constipation can be made if there is straining that takes up at least 25% of the time of defecation, dense (in the form of lumps) consistency of stool, a feeling of incomplete bowel movement, two or fewer bowel movements per week. To establish a diagnosis, it is enough to register at least 2 of these signs during the last 3 months. Diagnostic criteria for functional constipation (according to the Rome III criteria) should include 2 or more of the following sub-items, if the criteria for IBS are not met: - straining during 25% of bowel movements; - rough or hard stool in 25% of bowel movements; - a feeling of incomplete emptying for 25% of bowel movements; - sensation of anorectal obstruction for 25% of bowel movements; - manual interventions that facilitate 25% of bowel movements (for example, digital evacuation, pelvic floor support); - less than 3 bowel movements per week.

History It is necessary to identify the presence of diseases that may be associated with intestinal dysfunction, taking medications that cause constipation, or developmental abnormalities. Important anamnestic information is the duration of constipation, the presence or absence of pain and weight loss. Sharp pain is rare in patients with functional constipation. They are more likely to experience a feeling of discomfort and fullness in the abdominal cavity during stool retention. Intense pain before and during defecation, especially in patients with newly developed constipation, is more typical of stenotic processes in the intestines. However, they can also be observed in patients with irritable bowel syndrome.

Physical examination data Objective examination of patients with functional constipation is not very informative. With organic constipation, pallor and dryness of the skin are possible (for example, due to tumor intoxication of the body), a visual increase in the abdomen in size, there may be pain on palpation of certain parts of the intestine, compaction along the intestine due to intestinal spasm, the presence of dense feces, sometimes a tumor can be palpated colon. With dynamic intestinal obstruction, there are usually no peristaltic sounds, but with mechanical obstruction, there is asymmetry of the abdomen, increased, often visible to the eye, peristalsis, sonorous noises and a “splashing” noise during auscultation. Mandatory methods of examining the intestines for constipation include digital examination of the rectum. It makes it possible to judge the tone of the anal sphincter, identify anal polyps, hemorrhoids, anal fissures, and neoplasms located immediately behind the sphincter. An empty rectal ampulla may be due to intestinal obstruction. With constipation, feces are usually compacted, have the appearance of dry dark balls or lumps, and resemble sheep's feces. Sometimes stool can be bean-shaped, ribbon-shaped, or cord-shaped. Long-term constipation can cause various complications: proctosigmoiditis, hemorrhoids, fissures, paraproctitis, expansion and lengthening of the colon (acquired megacolon), reflux enteritis (due to the reflux of intestinal contents from the cecum into the small intestine), rectal/colon cancer.

Mandatory laboratory tests - Clinical blood test (presence or absence of anemia, leukocytosis and accelerated ESR in patients with inflammatory phenomena); — clinical urine analysis; - fecal occult blood test; — bacteriological examination of feces; - thyroid hormones (decreased levels of thyroid hormones); - blood sugar; - blood electrolytes (hypokalemia, hypercalcemia).

Mandatory instrumental studies - Sigmoidoscopy and colonoscopy with biopsy - identification of organic processes (tumors); - plain radiography of the abdominal cavity in a vertical position - identification of organic processes (tumors), phenomena of intestinal obstruction (fluid levels in the intestinal loops, intestinal segments distended with gas proximal to the site of obstruction and the complete absence of gas distal to this site); - irrigography with double contrast and passage of a contrast mass through the intestines - to identify violations of motor function and tone of the colon; - ultrasound examination of the abdominal cavity and pelvic organs - identification of organic pathology of the abdominal organs, retroperitoneal space and pelvis. Additional laboratory and instrumental investigations Anal manometry, defecography, electromyography of the pelvic floor muscles - to identify stasis of intestinal contents in the rectum, to differentiate constipation due to intestinal hypokinesia from difficult defecation due to pelvic floor dysfunction, impaired neuromuscular coordination of the act of defecation.

Differential diagnosis The primary goal is to exclude organic pathology of the intestine and other organs of the abdominal cavity, retroperitoneum and pelvis, in which constipation is only one of the symptoms. The presence of symptoms of “anxiety” (asthenic manifestations, fever, weight loss, anemia, increased ESR, the presence of blood in the stool) requires the exclusion of organic pathology of the intestine and other organs of the abdominal cavity, retroperitoneum and pelvis, in which constipation is only one of the symptoms.

Consultations with specialists Required: - gastroenterologist; - proctologist; - gynecologist (for women); - urologist (for men). If indicated, see an endocrinologist.

Treatment

The goal is to eliminate the cause leading to impaired bowel movement, normalize the propulsive ability of the colon, and regulate the process of bowel movement.

Treatment methods It is necessary to convince the patient to give up the habit of systematically giving himself enemas and explain to the patient the need to develop the habit of emptying the intestines at a certain time of day, while teaching him to regulate bowel movements with the help of nutrition, lead a more active lifestyle, and perform physical exercises to strengthen the muscles of the anterior abdominal wall and pelvic floor. In addition, it is necessary to drink a sufficient amount of liquid (1.5-2 liters per day), including at least 250 ml of mineral water in the morning on an empty stomach. For patients with constipation and hypomotor dyskinesia, mineral waters "Batalinskaya", "Essentuki No. 17" 150-200 ml cold 2-3 times a day are recommended, and for hypermotor dyskinesia - "Slavyanovskaya", "Essentuki No. 4" warm in the same doses. You should follow a diet with a mandatory morning breakfast. The diet of patients with constipation should contain foods with an increased amount of plant fiber (vegetables, fruits - at least 400 g per day, especially prunes, dried apricots, bananas and apples), fermented milk products, fats, mainly of plant origin. We can recommend that patients eat flaxseed, beets, corn, oatmeal, pearl barley, buckwheat porridge, and meat containing a large amount of connective tissue. It is recommended to limit rice, semolina, chocolate, baked goods, confectionery and pasta in the diet. If changes in diet and lifestyle do not lead to the desired result, then it is necessary to move on to the next stage of treatment - drug therapy. Drug treatment Drug treatment depends on the identified cause of constipation. For psychogenic constipation: - tricyclic antidepressants (amitriptyline, doxepin) start with a dose of 10-25 mg/day, gradually increasing it to 50 (150) mg/day, the course of treatment is 6-12 months; - anxiolytics (improves sleep quality, normalizes psychovegetative symptoms typical of neuroses and psychosomatic pathologies) - etifoxine 50 mg 2-3 times a day, course of treatment - 2-3 weeks. For dyskinetic constipation of the hypomotor type: - prokinetics (metoclopramide or domperidone) 10 mg 3 times a day before meals for 10-14 days; - 5HT4 receptor agonists - mosapride citrate 2.5 mg and 5 mg orally 3 times a day after meals, course of treatment - 3-4 weeks. For increased peristalsis and intestinal spasms Selective antispasmodics: myotropic (mebeverine 200 mg 2 times a day for 10-14 days, pinaveria bromide 100 mg 3 times a day for 7 days, then 50 mg 4 times a day for 10 days) and neurotropic (priphinium bromide 30-90 mg per day for 10 days). In the presence of severe intestinal dysbiosis (pathogenic flora, etc.): - antibiotics: erythromycin 250-500 mg 4 times a day; - probiotics. If there is no effect from the use of other drugs, or at the first stage of treatment of constipation, in order to more effectively restore the lost bowel reflex, laxatives are prescribed: - Forlax 1-2 sachets per day at the end of meals every morning; - lactulose 15-45 ml 1-2 times a day; — Senadexin 1-3 tablets 1-2 times a day; — bisacodyl 1-2 tablets 1-2 times a day or 1 suppository per rectum before bedtime; — guttalax 10-15 drops before bedtime; — mukofalk – 1-2 sachets 1-2 times a day; — softovak 1-2 teaspoons at night; - docusate sodium 0.12 g per rectum in the form of microenemas if the patient has the urge to defecate. The laxative effect occurs 5-20 minutes after administration of the drug into the rectum. Castor, Vaseline and olive oil can also be used. With occasional use of laxatives (in the absence of contraindications), their use is safe, but with long-term (over 6-12 months) use, psychological dependence and the phenomenon of addiction can develop. Therefore, constant and daily use of laxatives can be recommended only for special groups of patients (for example, cancer patients). The use of enemas for chronic constipation should be limited to periodic one-time use. Thus, in patients with habitual constipation, alternating water-oil enemas (volume 300-400 ml) with cleansing enemas (once a week) can be used in order to restore a reduced or lost reflex.

Prevention

Compliance with nutritional recommendations (mandatory morning breakfast, sufficient content in the diet of foods with a high amount of plant fiber (vegetables, fruits - at least 400 g per day, prunes, dried apricots, bananas and apples are especially recommended), fermented milk products, fats, mainly vegetable origin. You can recommend that patients eat flaxseed, beets, corn, oatmeal, pearl barley, buckwheat, meat containing a large amount of connective tissue and limit the diet to rice, semolina, chocolate, baked goods, confectionery and pasta). It is necessary to drink a sufficient amount of fluid (1.5-2 liters per day), including at least 250 ml in the morning on an empty stomach. You should lead a more active lifestyle and perform physical exercises to strengthen the muscles of the anterior abdominal wall and pelvic floor. Quitting the habit of systematically giving yourself enemas.

Constipation in a child - symptoms and treatment

Main directions:

• change in lifestyle, behavior;
• dietary recommendations;
• treatment with medications;
• herbal treatment;
• balneotherapy;
• Biofeedback therapy (biofeedback);
• physiotherapy, exercise therapy (physical therapy).

Increased physical activity

The basis of constipation treatment is lifestyle changes: walking, attending sporting events, active games in the fresh air. This is especially necessary for children who sit for a long time at the computer or in front of the TV. These changes should provide an attractive alternative to their usual pastime.[1][7]

Dietary recommendations

• Increasing fiber in the child’s diet. A balanced diet should include high-quality products containing dietary fiber (cereals, wheat bran, berries, baked apples, fruits and vegetables). The consumption of refined and easily digestible foods should be kept to a minimum.[4]
• Selection of infant formula. Infants who are bottle-fed benefit from infant formulas that contain carob gum (“Frisovom”, “Nutrilon Antireflux”), fermented milk mixtures (“Nan Fermented Milk”), mixtures with lactulose (“Semper Bifidus”) and others.[ 2] In addition, it is necessary to introduce complementary foods according to age.

Increasing the volume of fluid consumed

When treating constipation, it is important to control the water regime. Water is necessary to form feces and facilitate their passage through the intestines. If there is not enough water, the feces become denser. It is better to drink liquid half an hour before meals or two hours after meals.

Drugs

• prebiotics containing lactulose (“Duphalak”, “Portalak”), “Hilak forte”, “Eubikor”, monoprobiotics (“Bifidumbacterin”, “Probifor”), polyprobiotics (“Bifiform”, “Bifidum bag”, “Maxilak”) - course treatment (3-4 weeks);
• choleretic drugs (“Holosas”, “Hofitol”, “Galstena”);
• laxatives;
• based on the coprogram, enzymes (Creon, Pangrol, Mezim) can be prescribed - a course of treatment (two weeks);
• for spastic constipation, antispasmodics are prescribed (“Papaverine”, “Drotaverine”, “Buscopan”, “Duspatalin”).[1][6]

When using laxatives, remember the following rules:

• Long-term use of laxatives is not recommended.
• Laxative doses must be selected individually.
• You should try not to simultaneously take (prescribe) drugs that act at different levels of the gastrointestinal tract.
• In childhood, you can use only those drugs that are not addictive (Lactulose, Forlax, Eubicor, seaweed, etc.).

Biofeedback therapy involves teaching a child to consciously regulate the tone of the pelvic floor muscles.

Physiotherapy treatments include electrophoresis, SMT (sinusoidal modulated currents) and reflexology.

What not to do when your child is constipated

When a child is constipated, he should not be scolded or forced to sit on the potty. You should not give certain foods that inhibit intestinal motility: quince, pear, persimmon. The amount of flour and meat foods should be reduced.

Urgent measures

Before going to the doctor, you can give your child a laxative, put a suppository, or give a microenema.

How to give a child an enema

A cleansing enema is performed to free the lower intestines from feces.

The enema technique is not complicated; it can be done at home. But, it is advisable that the procedure be supervised by a health worker for the first time.

The room where the procedure is performed should not be cold. You need to prepare the pear of the required volume in advance. The temperature of the injected liquid should be between 22 and 26 ℃. If the child is under one year old, he should be placed on his back. Older children lie on their left side. The bulb needs to be filled with liquid, air released, and the tip lubricated with Vaseline or baby cream. Raise the upper buttock and insert the tip of the bulb into the anus 3-5-7 cm (depending on age). Squeeze the bulb and introduce the contents. After removing the bulb, squeeze the child’s buttocks for a few minutes.

Bowel movement training

When the functioning of the pelvic floor muscles is impaired, biofeedback therapy is an effective method. The goal of therapy is to teach the patient to control the muscles of the pelvis and obturator apparatus of the rectum. Patients may be older children who are able to understand the task.

Position: lying on your side, a sensor connected to a computer is inserted into the anus.

The child’s task: to increase muscle tension to appear or increase any animation effect on the screen.

Duration of therapy: once a week for five weeks.

Folk remedies

For constipation, it will be useful to consume mixtures of dried fruits (figs, dried apricots, prunes), baked apples, iodine-containing fruits (kiwi, feijoa).

The role of the doctor and pharmacist

Unfortunately, not only local general practitioners, but also gastroenterologists, for various reasons, cannot always find time during an appointment and tell patients in detail about modern methods of preventing and treating constipation. Therefore, it is pharmacists who should explain to customers that laxatives do not treat, but only relieve the symptom of the disease. However, in most cases, the patient does not even reach the doctor. When the first symptoms appear, people prefer to save time and just go to the pharmacy. The chief worker has more contact with the patient than the doctor. Therefore, the pharmacist must know the features of all laxatives, the rules for taking them and contraindications in order to give individual, competent advice to each buyer. In addition, the chief minister is obliged to inform the client that timely consultation with a doctor for chronic constipation will help identify their cause, increase the likelihood of cure and reduce the risk of complications .

Only a doctor can choose the optimal management strategy for a patient with prolonged constipation. A patient’s prolonged struggle with constipation on their own, without consulting a doctor, only complicates subsequent diagnosis and identification of the underlying cause.

Constipation of functional origin in children (view through the prism of the Rome Consensus IV)

Functional disorders of the motility of the digestive organs, in contrast to those caused by structural (organic) changes in a particular organ, are associated with disturbances in its nervous and/or humoral regulation. The development of such diseases, including constipation of functional origin (FFO), is based on a disorder of the so-called “brain-gut axis”, dysregulation of the gastrointestinal tract (GIT) by the central nervous system (CNS). Various psycho-emotional and social factors thus influence the functional state of the digestive organs, in particular their motility, accelerating or slowing it down. On the other hand, under these conditions the reaction of the central nervous system to the ascending currents emanating from the gastrointestinal tract is also disrupted, which leads to its inadequate response. Disorders observed at the level of the gastrointestinal tract itself have also been identified, including from the enteric nervous system and the receptor apparatus, the state of which is influenced by the internal environment in the lumen of the gastrointestinal tract, intestinal microflora, the state of permeability of the epithelial barrier and many other factors.

All of these aspects are united by the so-called biopsychosocial model of functional disorders of the digestive system, according to which symptoms develop due to a combination of several known physiological determinants: impaired motility, visceral hypersensitivity, changes in mucosal immunity and inflammatory potential, including changes in the bacterial flora, as well as changes regulation of the axis of the central nervous system - the enteric nervous system as being influenced by psychological and sociocultural factors [1].

In the light of modern ideas about functional disorders of the digestive organs, they are defined as stable complexes of gastrointestinal symptoms that develop due to a combination of disorders of motility, visceral sensitivity and mucosal homeostasis in certain social and environmental conditions and/or in the presence of psychological personal characteristics, family predisposition [1] .

Over the past decades, specialists from all over the world have been joining forces to systematize and deepen their understanding of this group of diseases in order to develop a unified classification and general principles of diagnosis and treatment. Thus, in 1990, the first consensus on functional disorders of the digestive system was developed, called the Rome Consensus (Rome Criteria). In 2016, the next, fourth, revision of this consensus took place, replacing the Rome III criteria (2006). It should be noted that the changes made are largely clarifying in nature, and many fundamental provisions remain the same. As in the Rome III criteria, pediatric aspects are allocated to two classification sections (G and H), separating two age groups: G. Functional impairment in children from birth to 4 years of age, H. Functional impairment in children over 4 years of age. FTDs within the framework of the Rome Consensus are represented by irritable bowel syndrome (IBS) and functional constipation (FC). Also related to this problem are childhood dyschezia and non-retentive fecal incontinence.

Below are the relevant sections of the classification of functional disorders of the digestive organs within the framework of the Rome criteria III and IV, including those relating to adult patients accompanied by constipation (Table 1).

The diseases designated in the Rome criteria do not always coincide with the nosological units identified by the International Classification of Diseases, which must be used in everyday practice to code the diagnosis. Below are the disease codes with FFZ according to ICD-10.

ICD-10 CODES

• K 58. Irritable bowel syndrome (IBS)
• By 58.0. IBS with diarrhea
• To 58.9. IBS without diarrhea
• By 59.0. Constipation
• To 59.1. Functional diarrhea
• To 59.2. Neurogenic excitability of the intestine, not classified elsewhere
• To 59.8. Other specified functional bowel disorders
• To 59.9. Functional bowel disorders, unspecified

Diagnostic criteria for diseases and conditions associated with constipation of functional origin, in accordance with the Rome IV criteria (2016), are given in Table. 2.

IBS, as follows from the above consensus, can only be diagnosed in children over 4 years of age. By definition, IBS refers to functional disorders of gastrointestinal motility in the form of constipation and/or diarrhea, accompanied by abdominal pain. In the previous edition of the consensus, the fundamental difference between the concept of FF and the concept of IBS was the absence of pain in a patient with FF. The interpretation of the differences between IBS and FZ was preserved in the Rome IV criteria in the section devoted to intestinal motility disorders in adult patients. In addition, the latest consensus indicates that pain in IBS is somehow related to bowel movements. In the Rome III criteria, the wording was more categorical: “pain goes away after defecation.” The diagnostic criteria for IBS in the Rome III criteria for adults and children were similar, but have changed in the latest edition.

According to the Rome IV criteria, abdominal pain is not only a sign of IBS, but also does not contradict the diagnosis of FZ. This change is due to the fact that, according to studies, 75% of children of various ages with constipation experience abdominal pain [6]. Moreover, the 2016 criteria emphasize that in IBS with constipation, pain does not resolve with resolution of the constipation itself, and children whose pain resolves after defecation should be diagnosed with FZ, but not IBS. As for FZ, the leading symptom in this case is constipation, and abdominal pain (and bloating), although they may be present in the clinical picture, are still secondary symptoms.

Attention should also be paid to time aspects. A diagnosis of IBS can be made if abdominal pain combined with constipation occurs on at least 4 days per month for at least 2 months before diagnosis. In the case of FZ, signs should be observed at least once a week for at least 1 month [4, 5, 7].

You should also pay attention to the so-called “anxiety” symptoms, which exclude the diagnosis of FP [4, 5]:

• early onset of constipation (<1 month of age);
• passage of meconium more than 48 hours after birth in a full-term newborn;
• family history of Hirschsprung's disease;
• ribbon stool;
• blood in the stool in the absence of anal fissures;
• developmental delay;
• fever;
• vomiting bile;
• thyroid abnormality;
• severe bloating;
• perianal fistula;
• abnormal position of the anus;
• no anal reflex or cremasteric reflex;
• decreased lower limb muscle strength/tone/reflexes;
• a tuft of hair above the spinous process of the vertebra (an indirect sign of spina bifida);
• depression in the sacral area (indirect sign of spina bifida);
• deviation of the intergluteal groove;
• severe fear during examination of the anus;
• scars in the anal area.

The main goal in the treatment of FP is to ensure regular, painless bowel movements with a soft consistency, as well as to prevent the accumulation of stool.

This can be achieved as a result of a set of measures: education of parents and the child, behavior correction, daily use of laxatives and changes in diet. It must be emphasized that treatment of FP should be carried out differentially, taking into account the age of the child and the stage of FP: compensated, subcompensated and decompensated.

The first stage of treatment for FP is explanatory work with parents and children (older), when the possible causes and mechanisms of constipation are explained. Sometimes FFP can be caused by the peculiarities of the family environment or aggravated by them, so the help of a family psychologist may be needed.

Behavioral therapy is based on developing a toileting routine to achieve regular bowel movements. A prerequisite for effective defecation is to provide good foot support, which can be ensured by having a low bench in the toilet for the child to rest his feet on. If defecation is unsuccessful, the child should under no circumstances be punished, and, conversely, should be praised if successful [8].

Nutritional correction for constipation is a mandatory component of treatment: a diet including grains, fruits and vegetables is indicated [9]. Insufficient dietary fiber intake in the daily diet is a risk factor for constipation [8]. The United States National Academy of Sciences has proposed a dietary fiber intake of 14 g per 1000 kcal (15 g per day for a one-year-old child), and the Nutrition Committee of the American Academy of Pediatrics (AAP) - 0 .5 g/kg (up to 35 g/day) [10–12]. The Russian Society of Pediatric Gastroenterologists recommends the following calculation of dietary fiber intake: add 5–10 g per day to the child’s age ((5–10) + n, where n is the age in years, i.e. 6–11 g/day for a one-year-old child) [13]. It is recommended to exclude foods that delay bowel movement from the diet (Table 3). “Waste” food, pureed food, “food on the go”, “snacks” are not recommended. On the contrary, crumbly food, meat/poultry/fish “in pieces” are shown. A “voluminous” breakfast is required - to stimulate the “gastrocecal reflex”.

When eating coarse fiber, ensure adequate water intake. Only the simultaneous consumption of 25 g of plant fiber and at least 2 liters of liquid per day accelerates intestinal transit and softens stool [14].

Drug (supportive) therapy

Painless stools of soft consistency are achieved with the help of laxatives. When developing treatment tactics for FD, an individual treatment program taking into account the premorbid background and concomitant pathology is extremely important. The main problem in the treatment of FD in children is age restrictions when using laxatives. Along with laxatives, the administration of normokinetics (trimebutine), pre- and probiotics, as well as antispasmodics and choleretic agents in some patients is effective.

In domestic practice, among all groups of laxatives used in pediatric practice, preference is given to drugs with an osmotic effect. Their main mechanism of action is to soften the stool by retaining water, which facilitates the transport of chyme and makes defecation less difficult. At the same time, the volume of stool increases, intestinal motility is stimulated, and transit is normalized. This group of drugs includes drugs based on lactulose, lactitol, and macrogol. A special feature of lactulose and lactitol is their prebiotic effect. Antispasmodics of plant origin, which have an effect on the secretion of gastric juice and intestinal motility, can be considered as additional means of treating FFP [9]. Clinical experience in the treatment of constipation indicates the advisability of using choleretic drugs in the complex treatment of constipation. The general principles of differentiated therapy for FP, depending on the nature of the pathological process, are given in Table. 4.

Thus, constipation of functional origin, being a common pathology of childhood, requires attention and often painstaking differential diagnosis. Timely diagnosis of functional disorders of the digestive organs and their treatment are necessary to prevent the development of complications and their evolution into organic pathology.

Literature

1. Drossman DA The functional gastrointestinal disorders and the Rome III process // Gastroenterology. 2006; 130:1377–1390.
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S. V. Belmer*, 1, Doctor of Medical Sciences, Professor A. I. Khavkin*, Doctor of Medical Sciences, Professor D. V. Pechkurov**, Doctor of Medical Sciences, Professor

* Federal State Budgetary Educational Institution of the Russian National Research University named after. N. I. Pirogova Ministry of Health of the Russian Federation, Moscow ** Federal State Budgetary Educational Institution of Higher Education SamSMU Ministry of Health of the Russian Federation, Samara

1 Contact information

CHRONIC CONSTIPATION

Chronic constipation (CC) is usually understood as a complex of various symptoms associated with disruption of the bowel movement process.

Most often, constipation is defined either as infrequent bowel movements (less than three times a week), or as the presence of difficulty during bowel movements with the release of intestinal contents of less than 35 g per day [5, 13]. A practitioner should use the term “constipation” to define a condition characterized by two or more of the main symptoms listed in the table [3, 12, 22] (Table 1).

In order to establish the presence of chronic disease, two of these signs recorded over the last three months are sufficient. It is important to indicate to the patient the inconvenience and anxiety associated with a change in the usual rhythm of bowel movements. It should be remembered that a number of practically healthy people have a rare defecation rhythm that does not cause them any inconvenience [22].

Until recently, it was believed that on average about 12% of the adult population suffers from chronic constipation [15]. Today in the UK alone, according to some data, more than 50% of the population considers themselves to be constipated; in Germany the number is 30% and in France it is around 20%. In Russia, as in the UK, constipation is believed to affect more than 50% of the population [15].

Speaking about the pathological mechanisms that cause constipation, it should first of all be noted that chronic constipation can arise as a result of the influence of a very large number of etiological factors that have one common link in pathogenesis as their point of application - a violation of the motor activity of the gastrointestinal tract as a whole and the colon in particular [12, 24, 27]. Hence, there are various approaches to the classification of constipation, a large number of “working” classifications [2, 3, 4, 21, 26] in the absence of a single generally accepted one today.

Before characterizing the pathogenesis of chronic disease, it is necessary to recall some physiological mechanisms that ensure the normal functioning of the gastrointestinal tract and its motor activity. First of all, this is the presence of contents in the intestine, which, in quantity and quality, is a physiological irritant for peristalsis. In addition, there are a number of other mechanisms: a) the presence of an undisturbed muscular system, external and intrinsic innervation of the intestines; b) preservation of endocrine and paracrine regulation; c) the presence of a normal reflex from the rectum and unimpaired function of the pelvic floor muscles; d) absence of obstacles to peristalsis [1, 15, 24].

Disturbances in the system that ensures normal intestinal motor function can lead to the formation of chronic disease, since any type of constipation is based on one or another type of colonic motility disorder - dyskinesia, which plays a leading role in its pathogenesis. It should be noted that both hypomotor and hypermotor dyskinesia (the latter is even more common - by 20-25%) can lead to chronic disease [15].

The normal functioning of the rectum, anal sphincter, pelvic floor muscles, and abdominal wall is important in the mechanism of bowel movement. It is known that defecation is a voluntary and suppressed act, depending not only on purely biological components, but also on social conditions. Disruption of the rhythm of bowel movements, suppression of unconditioned (gastrocolytic, orthostatic) physiological reflexes leads to an increase in the sensitivity threshold, accumulation of feces in the rectum, and disruption of its propulsive function. It is characteristic that with this type of constipation, disturbances in the motor function of other parts of the colon, as a rule, are not observed. Hereditary constitutional features, and in particular the presence of connective tissue dysplasia syndrome in the patient, are of great importance in the formation of chronic disease associated with the function of the rectum.

Coordination of the activity of the pelvic floor muscles is also important. In the presence of dysfunction of the puborectal muscles and (or) the external sphincter of the rectum, defecation disorder may also appear, expressed in a feeling of incomplete emptying of the rectum. This type of constipation is also called “muscular” [3].

Chronic constipation (forced constipation) can also be caused by pathological processes in the rectal area, accompanied by pain during defecation (hemorrhoids, cryptitis, papillitis, anal fissure, ulcerative lesions of the anal canal in Crohn's disease, rectoanal localization of syphilis, tuberculosis, rectal cancer ).

Thus, two main forms of constipation can be distinguished: constipation, which is caused by the slow movement of contents through the colon, and constipation associated with dysfunction of the rectum and (or) anal sphincter. In addition, there are functional and organic (mechanical) constipation, intestinal and extraintestinal obstipations [24], constipation with normal and enlarged colon size [3], primary, secondary, idiopathic [12], constipation subdivided according to the topographic principle, in accordance with “functional units” of the colon [4], etc.

Among constipation associated with the slow movement of contents through the colon, the most common are constipation, which is based on the patient’s dietary habits (dietary, simple constipation). This type of constipation is functional in nature and is not a serious disease. The main manifestations of this pathology are: rare bowel movements, feces are harder, their excretion is difficult and is accompanied by unpleasant, sometimes painful sensations. Other causes of non-mechanical constipation, leading to slow movement of contents through the intestines and not associated with intestinal diseases, are listed in Table. 2.

With idiopathic constipation, the most thorough examination does not allow us to establish the cause of constipation. The idiopathic form of chronic disease is accompanied by pathological changes in the neuromuscular apparatus of the colon, a decrease in its propulsive activity, stimulated by food intake [24]. Regarding the clinical features of constipation listed in Table. 2, it should be noted here that the most “rich” in symptoms are the forms associated with aganglionosis (hypogangliosis) of the colon, as well as hypochondriacal constipation. In the first case, the severity of the clinic mainly depends on the length of the aganglionic segment of the colon. If a small area of ​​the intestine is affected, then initially such constipation develops as simple, gradually acquiring an increasingly persistent character and rigidity to therapy. During this period, the patient develops typical signs of this disease: a large abdomen, vomiting, significant dilation of the area of ​​the colon located proximal to the aganglionic segment, absence of feces in the ampulla of the rectum, inflammation, ulcerative lesions of the mucous membrane in the enlarged, affected area of ​​the colon. Hypochondriacal constipation is characterized by changes in the patient’s psyche, expressed in the patient’s fixation on bowel activity and in exorbitant demands placed on bowel regularity. Patients often torture themselves with various kinds of manipulations in order to more completely empty the intestines, abuse enemas, laxatives, and disrupt the normal reflex of emptying the rectum. Stool retention, usually manifested after a bowel movement with a laxative or an enema, psychologically traumatizes patients, forcing them to take additional doses of laxatives, which can result in persistent diarrhea syndrome (the intestine loses the ability to absorb water), loss of fluid, electrolytes, especially potassium. A “vicious circle” is created, further aggravating the constipation syndrome with pronounced general phenomena, including dehydration, hypokalemic paralysis, and an increase in residual nitrogen in the blood. Pseudostrictures form in the large intestine, it expands, especially its right parts. In patients with chronic disease, abdominal bloating can often be detected, the skin becomes pale, sometimes with a yellowish-brown tint, loses elasticity, and eczema, urticaria, and pyoderma may appear on it. With advanced constipation, the large intestine gradually loses haustration, expands, and its mucous membrane often becomes dark in color (with laxative abuse). The cause of chronic constipation may be direct damage to the colon (intestinal causes of constipation). X3, which have an intestinal cause, are divided into constipation associated with a mechanical obstacle that impedes the movement of contents through the intestines (organic blockage of the lumen of the colon); constipation during inflammatory processes in the colon and chronic diseases associated with dysfunction of the muscular layer of the colon (primarily functional). Organic (mechanical) constipation includes: extraluminal and intraluminal tumors, chronic volvulus of the colon, intussusception, hernias, strictures, intestinal diverticula, chronic amoebiasis, lymphogranuloma venereum, tuberculosis, endometriosis, radiation strictures and narrowings that developed after surgical interventions, etc.

In the case of the tumor nature of constipation (colon adenocarcinoma), the clinical picture of the severity of chronic disease depends primarily on the localization of the process - the lower along the intestine the tumor is located, the more pronounced the signs of constipation. Of the characteristic features of constipation caused by a tumor, first of all, a small previous history of constipation and an increase in the clinical picture should be noted. It is necessary to note the importance of the symptom of alternating constipation and diarrhea, as well as the optional presence of pronounced dilatation of the intestine above the lesion.

Features of constipation in endometriosis are a clear relationship with the menstrual cycle, concomitant severe pain and sometimes urinary disorders.

Diverticulosis of the colon is characterized by the presence of pain associated with eating (pain-associated gastrocolytic reflex). Diverticulosis has a number of characteristic signs: the presence of a defect in the filling of the intestine over a significant extent due to the formation of crescent-shaped folds of the intestinal mucosa, sometimes completely filling the intestinal lumen.

Constipation can also be caused by inflammatory diseases of the colon, as well as dysfunction of the colon of non-inflammatory origin - “irritable bowel syndrome” (IBS). The cause of chronic disease in pathological processes of an inflammatory nature occurring in the colon is secondary damage to the Meissner and Auerbach plexuses. Increasingly, IBS is becoming the main cause of constipation syndrome [1, 2, 7, 16, 18]. Under conditions of neuro-emotional overload, stress, especially chronic stress, the activity of the central and autonomic nervous systems is disrupted, which leads to an imbalance of catecholamines, biogenic kinins, intestinal hormones (motilin), endogenous opioids and entails dysregulation of intestinal activity, mainly its motility (primary dyskinesia of the colon).

A change in the sensitivity threshold of visceral receptors, which determine the motor-evacuation function of the intestine, is also of certain importance. A major role in the development of chronic disease against the background of IBS is played by disturbances in diet and bowel movements, as well as the nature of nutrition. Among the features of the clinical picture of obstipation that developed against the background of IBS, it is necessary first of all to note the pain syndrome that is relieved after defecation, a small volume of stool, its fragmentation like a “sheep’s stool,” and the release of a large amount of mucus. Mucus is often separated with feces in the form of membranes, casts of the intestine. The intensity of the pain syndrome varies from a feeling of fullness along the intestines, pressure in the lower abdomen to severe intestinal colic. Sometimes, with right-sided localization of pain, a diagnosis of acute appendicitis may be erroneously made and even surgery may be performed. Characterized by the presence of widespread pain on palpation along the course of the colon, the presence of spastically contracted areas of the colon, sometimes with concomitant expansion of the intestine located proximally, colonostasis, coprostasis, in some cases severe, with the formation of coprolites. Patients often complain of pain in the sacrum, migraine-type headaches, dysphagia, autonomic vascular reactions, sweating, sleep disturbance, sometimes drowsiness, etc. The absence of symptoms at night and relief of symptoms with sedatives is also typical. Unlike advanced habitual constipation, digital examination rarely reveals feces in the rectum; they accumulate in front of the rectosigmoid angle (spastic processes in the sigmoid colon). X-ray examination of this type of chronic disease reveals the presence of pronounced spasms in the area of ​​the sphincters of the colon and a decrease in the propulsive activity of the intestine.

Among constipation associated with rectal pathology (Table 3), the most common is habitual constipation. Its cause is an increase in the sensitivity threshold of rectal receptors. Disruption of the rhythm of defecation is facilitated by frequent changes in the usual rhythm of life, business trips, job changes, working at night, etc. Constantly ignoring the urge to defecate leads to the fact that the receptors of the rectum stop responding to irritation. Fecal masses first accumulate in the sigmoid and then in the rectum (advanced habitual constipation). Unlike constipation in IBS, in the case of habitual constipation there are no psychosomatic disorders and no reaction to psychotropic drugs. With advanced habitual constipation (overstretched rectal syndrome) [3], the urge to empty occurs only after a significant increase in intrarectal pressure. Unlike Hirschsprung's disease, digital examination in patients with habitual advanced constipation always reveals stool in the rectum. With habitual constipation, in all cases a positive reaction to a cleansing enema is observed, since the reflex is reduced, but present.

Considering the variety of types of constipation, when examining patients with chronic disease in order to clarify the mechanism of its development in each specific case, it is necessary to follow a certain sequence of diagnostic search. In table 4 presents the main categories of tests.

Differentiated therapy for chronic constipation

It must be remembered that therapy for chronic disease should be selected in accordance with its type. It is quite obvious that with simple constipation associated with nutritional factors, stagnation of contents in the colon, treatment mainly consists of normalizing the patient’s diet, prescribing a diet that stimulates the propulsive activity of the colon: food containing plant fiber, including dietary bran, seaweed , flaxseed, corn, oatmeal, pearl barley, buckwheat, raw vegetables and fruits (at least 200 g per day), especially prunes, dried apricots, bananas, apples. The use of meat containing a large amount of connective tissue, fermented milk products, dry white grape wines, beer, kvass, fats, mainly of vegetable origin (olive, corn oils) is indicated. A slag food load is especially indicated for hypomotor intestinal dyskinesia. To stimulate intestinal motility, it is advisable to drink one or two glasses of cold water or fruit juice on an empty stomach with the addition of one tablespoon of xylitol or honey. The diet for hypermotor dyskinesia of the colon is more gentle, low in dietary fiber (boiled vegetables, vegetable fats). It should be remembered that the introduction of food bran into the diet should begin with small doses. Persons whose chronic disease is caused by a sedentary lifestyle, physical inactivity, and weakening of the muscles of the anterior abdominal wall should be prescribed therapeutic exercises, swimming, massage, and self-massage of the abdominal wall. The posture when emptying is very important (squatting, with a bench placed under your feet). With habitual constipation, the development of a conditioned reflex to defecation is extremely important (defecation at a strictly defined time, for example in the morning, in the absence of morning rush; getting out of bed early). If diet therapy is ineffective or insufficiently effective, medications must be prescribed. For hypomotor dyskinesia of the colon, the use of prokinetics is indicated, in particular cisapride (Coordinax, Peristil). Cisapride increases the tone and significantly enhances the propulsive motility of the colon, accelerates the passage of contents through the colon, increases the tonicity of the sphincters, while the drug has no side effects from the central nervous system. The use of cisapride is quite effective in patients with IBS with intestinal pseudo-obstructive syndrome [19]. Taking cisapride at a dose of 10 mg three times a day or in suppositories of 30 mg leads to an increase in the frequency of bowel movements from 1.5-2.7 times a week to 3.5-5.3 times, and allows reducing the use of laxatives [19] . Treatment with cisapride is effective for severe constipation in people with spinal cord lesions, with constipation syndrome due to scleroderma, muscular dystrophy, as well as in people with anorexia nervosa [23, 26]. For scleroderma, the administration of a somatostatin analogue, octreotide, is also indicated [16]. This drug has also proven itself in patients with functional obstipation syndrome. For patients with idiopathic constipation, cisapride and debridate are equally indicated, which restore the normal rhythm of evacuation of intestinal contents; in patients with idiopathic chronic constipation, cisapride restores impaired motor parameters. As a result of taking this drug, in particular, the sensitivity threshold of the intestine decreases, lost reflexes and the urge to defecate are restored [14]. The use of motilin mimetics (erythromycin, oleandomycin) has a positive effect on idiopathic constipation. Taking erythromycin (1 g per day for two weeks and 500 mg for the next two weeks) accelerates the movement of contents through the colon by half [16].

A more pronounced clinical effect for constipation associated with slow movement of contents through the colon is provided by the use of a combination of prokinetics with choleretic agents (allochol, lyobil) [19], with preparations from psyllium seed shells (mucofalk) [19]. The principle of action of the latter is to retain water in the intestinal lumen and increase the volume of stool. Promising drugs with a similar mechanism of action include the drug forlax (macrogol 2000), which causes an increase in the volume of intestinal contents and its softening due to the formation of additional hydrogen bonds with water molecules, its retention and accumulation in the intestinal lumen [9]. Typically, the following treatment regimen with Forlax is used: during the first three days, the patient receives 20 mg of the drug twice a day (morning and evening), then 10 mg twice a day. The course lasts two weeks. Forlax is especially effective (80%) in patients with hypomotor dyskinesia of the colon; it is somewhat less effective (66%) in patients with hypermotor dyskinesia. The use of the drug in patients with proctogenic constipation is inappropriate [6]. Methylcellulose preparations, the non-absorbable synthetic disaccharide lactulose (Duphalac, etc.), and agar-agar increase the volume of intestinal masses. The effect of taking lactulose is also explained by the fact that lactulose, entering the large intestine, acidifies its contents (the result of the action of intestinal bacteria that break down it). This property of the drug provides a good result for constipation associated with severe heart failure, after strokes, with drug-induced constipation and in pregnant women [8]. Lactulose is less effective in patients with proctogenic chronic disease.

For hypermotor dyskinesia (spastic phenomena), the use of debridate (trimebutine) 1-2 tablets three times a day for a month is indicated. The drug belongs to the endogenous peptides, enkephalins, and, by stimulating all types of opiate receptors, restores physiological control over motor skills, regardless of the nature of motor disorders [9]. A good effect in chronic disease against the background of IBS with a pronounced spastic component, especially in combination with hypertensive biliary dyskinesias (spasm of the sphincter of Oddi), is achieved by the use of the drug dicetel (pinaverium bromide), which is a powerful myotropic antispasmodic. The drug affects gastrointestinal motility, reduces the potentials, amplitude and frequency of slow waves [11]. The drug is usually prescribed one tablet three times a day with meals, the duration of the course of therapy is about 20 days. A good effect in IBS with pain is provided by the use of the calcium channel blocker spasmomen, as well as antispasmodics such as buscopan, metacin, gastrocepin and the homeopathic remedy spascuprel from Heel (Germany). It is also possible to take traditional antispasmodics (no-spa, papaverine), but the use of anticholinergic drugs is preferable. For constipation with a spastic component, warm oil enemas in a volume of 150-200 g are very effective. Often, chronic constipation due to IBS is accompanied by flatulence, which is difficult for patients to tolerate. In this case, the use of drugs that alleviate the condition of patients due to the sorption of gases is indicated. For this purpose, the drugs espumizan, disflatal and meteospasmil, containing the silicon derivative simethicone, are used. In case of severe bloating, accompanied by pain, a simultaneous one-time use of all three of these drugs is possible, as a result of which the phenomenon of flatulence is relieved in 30-45 minutes [11]. Activated carbon can also be taken.

For functional constipation, especially occurring against the background of dysbiotic processes, the use of a combination of prokinetics with eubiotics (agents that normalize the bacterial intestinal flora) is justified. Among the latter, Linex, Bifidumbacterin, Lactobacterin, Bifiform, “Biococktail-NK”, etc. have proven themselves well. In the presence of pathogenic flora, the administration of erythromycin, which simultaneously stimulates the motor activity of the colon [7], Intetrix, ersefuril, metronidazole, is especially indicated.

If the above therapy is ineffective, adequately selected laxatives are prescribed as a necessary measure, stimulating intestinal function due to chemical irritation of the receptor apparatus of the colon mucosa. First of all, these are products (regulax, tisasen, etc.), which contain anthraglycosides (senna, rhubarb, buckthorn), as well as chemicals: phenolphthalein, bisacodyl and guttalax (laxigal). The most preferable is taking the latter drug. The basis of guttalax is sodium picosulfate, which, hydrolyzed under the influence of intestinal microflora, enhances colon peristalsis. Preference should be given to drugs based on sodium picosulfate due to their lowest toxicity to the liver and intestinal microbial flora. A positive effect from taking these drugs is also found in cases of hypomotor, “senile” constipation. The dose of sodium picosulfate depends on the type of pathology. Thus, in case of chronic disease against the background of IBS, 10 drops of the drug are usually sufficient (dolichocolon - 20 drops), and in patients with an inert colon, a positive effect is observed after taking 24 drops. The residual positive effect after two to three days of taking Laxigal depends on the type of pathology. With mild motor impairment, it is observed within two weeks. It is characteristic that with long-term use of sodium picosulfate (three weeks or more) no addiction is observed [13]. For rectal forms of constipation, contact laxatives can be given in the form of suppositories, but their use should not be prolonged due to the possibility of irritation of the rectum. Enemas for chronic constipation should be used only periodically. Alternating water-oil enemas (volume 300-400 ml) with cleansing enemas (once a week) is especially recommended in patients with habitual constipation. This combination helps restore a reduced or lost bowel reflex. Physiotherapy, acupuncture, and psychotherapy provide a good effect for functional constipation. In the presence of internal prolapse of the rectal mucosa, even in the early stages (with light pushing), surgical treatment methods should be used.

In any case, it must be remembered that the treatment of chronic obstipation syndrome requires an individual approach.

For questions regarding literature, please contact the editor.

I. V. Mayev , Doctor of Medical Sciences, Professor

Table 1. Signs of chronic constipation

• Rare bowel evacuation (delayed bowel movement for more than 48 hours)
• Separation during defecation of a small amount of feces (stool weight less than 35 g/day)
• Separation of feces of high density, dryness, which injures the area of ​​the anus and leads to inflammatory processes
• Lack of feeling of complete bowel movement after bowel movement
• The presence of a feeling of blockage of contents in the rectum during pushing, which takes up more than 25% of the duration of bowel movement
• The need for strong pushing, despite the presence of soft rectal contents and the urge to empty the rectum, sometimes the need for digital removal of contents from the rectum

Table 2. Main causes (types) of chronic constipation associated with slow movement of contents through the intestines (not associated with intestinal diseases)

Nutritional reasons (simple constipation)

• General physical inactivity (sedentary lifestyle, bed rest)
• Heart failure (congestion), including portal hypertension

Metabolic/endocrine causes

• Hypothyroidism, diabetes mellitus, hypokalemia, hypercalcemia (of any etiology), hypo- or hypermagnesemia, pregnancy, uremia, pheochromocytoma, glucagonoma, porphyria
• Taking medications: anticholinergic/antispasmodic drugs; antidepressants, anticonvulsants; antiparkinsonian and antihistamine drugs; non-steroidal anti-inflammatory drugs, antihypertensive drugs (especially calcium channel blockers), diuretics; preparations containing bismuth, iron, calcium carbonate, aluminum hydroxide; ganglion blockers, opiates, laxatives (with constant use)
• Diseases of internal organs: scleroderma, viscero-visceral reflex, atonic constipation in acute cholecystitis, pancreatitis, appendicitis, etc.
• diseases of the central nervous system: cerebral palsy, multiple sclerosis, tabes dorsalis, tumors, Parkinson's disease, cerebrovascular accidents, Alzheimer's disease
• Diseases of the peripheral nervous system: aganglionosis of the colon (Hirschsprung's disease), hypo- or hypergangliosis, ganglioneuromatosis, lesions of the cauda equina, etc.
• Psychogenic constipation (depressive states, schizophrenia, anorexia nervosa, hypochondriacal states)
• Idiopathic constipation (inert colon or rectum)

Table 3. Chronic constipation associated with rectal pathology

• Habitual constipation
• Advanced habitual constipation
• Constipation due to neoplastic, inflammatory processes in the rectum (mechanical obstruction)
• Constipation that occurs due to disorders that cause functional obstruction of the defecation tract - internal (anterowall, circular) and external (anal) rectal prolapse
• Constipation with rectal hernia (usually anterior)
• Constipation due to achalasia of the rectum

Table 4. Directions of diagnostic search for chronic diseases

Tests

• To identify the presence and causes of slow movement of feces through the colon (careful collection of anamnestic data indicating the presence of various forms of constipation, an X-ray method using X-ray positive, radiopharmacological markers, electromyographic monitoring method)
• To exclude (detection) organic disease of the colon (irrigoscopy, colonoscopy)
• To identify dysfunctions of the anorectal region (functional proctological examination, including: electronic palpation and proctoscopy at rest, as well as with mechanical irritation, including pressure, X-ray defectography, manometry, electromyography)