Determination of the Laxative Requirement in a Disimpacted Patient

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Once the patient has been disimpacted, an arbitrary amount of laxative is started, usually a senna derivative. The initial amount is based on the information that the parents give about the previous response to laxatives, and the subjective evaluation of the megasig-moid on the contrast enema. The empiric dose is given and the patient is observed for the next 24 h. If the patient does not have a bowel movement in the 24 hours after giving the laxative, it means the laxative dose was not enough, and it must be increased. An enema is also required in order to remove the stool produced during the previous 24 h. Stool in these extremely constipated patients should never remain in the rectosigmoid for more than 24 h.

The routine of increasing the amount of laxatives and giving an enema, if needed, is continued every night until the child has a voluntary bowel movement and empties the colon completely. The day that the patient has a bowel movement (which is usually with diarrhea), a radiograph should confirm that the bowel movement was effective, meaning that the patient has completely emptied the rectosigmoid. If the patient passed stool but did not empty completely, the dose of laxative must be increased.

Since this condition covers a wide spectrum, patients may have laxative requirements much larger than the manufacturer's recommendation. Occasionally, in the process of increasing the amount of laxatives, patients throw up before reaching any positive effect. In these patients, a different medication can be tried. Some patients vomit all kind of laxatives and and are unable to reach the amount of laxative that produces a bowel movement that empties the colon.

Such a patient is considered intractable, and therefore a candidate for surgical intervention. Most of the time, however, the dosage that the patient needs in order to empty the colon completely, as demonstrated radiologically, can be achieved. At that dose, the patient should stop soiling because they are successfully emptying their colon each day, and because the colon is empty, they remain clean until the next voluntary bowel movement.

At this point, the patient and the parents have the opportunity to evaluate the quality of life that they have with that kind of treatment, understanding that this treatment will most likely be for life. There is an operation, a sigmoid resection, which provides symptomatic improvement, sometimes to the point that they do not need laxatives at all. Since this is a quality of life issue, it must be determined by the parents and the patient.

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Constipation Prescription

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