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| |    Understanding Constipation by Robert Needlman, M.D., F.A.A.P. reviewed by Laura Jana, M.D., F.A.A.P. Most cases of encopresis are the result of severe constipation. To understand constipation, it helps to know that the large intestine (colon) has two essential functions: It transports the feces from one end to the other along its length, and it absorbs water from the feces, which enter the colon as a liquid and exit as a formed stool. Constipation results when stool takes too long to pass through the large intestine. The longer the stool sits in the colon, the more water is absorbed from it, and the harder it becomes. Hard, dry BMs are painful to pass, so the natural response is to try to hold them in. Of course, this means that the BMs stay in the colon even longer and become even harder. Eventually, when they do pass, they may be so large that they cause a tear in the skin around the anus (anal fissure)--and, of course, that just makes the next large, dry stool all the more painful. So what starts as simple constipation can easily become a vicious cycle. Constipation becomes a vicious cycle in another way, too: As masses of hard stool build up in the colon, the colon stretches to hold them. As the muscles of the colon stretch more and more, they become weaker and weaker, and it takes longer and longer for them to push the stool along. Eventually a large mass of hard, dry stool just sits there in the colon and rectum, not going anywhere. How constipation causes fecal soiling As the rectum stretches to hold all this stool, it loses its normal stretch sensation. The child no longer feels the urge to go. When he strains or coughs or runs around, a small chunk of the larger mass breaks off and falls out onto his underpants. Chances are, he doesn't even feel it, because his whole anal area has become so desensitized. Children with encopresis also become desensitized to the smell, even though it's obvious to others. They know that they "stink" because other children tell them so, but they don't smell it themselves. Severe constipation can also cause soiling by liquid stool. When the colon has been stretched out by a large mass of hard stool, it stops working well. Liquid stool that comes in from above is able to leak down among the cracks and crevices in the rocklike stool mass. When this liquid stool reaches the rectum, it simply leaks out because the overstretched rectum has lost the reflexes that normally hold stool in the rectum and the sensations that tell the child that he has to go to the bathroom. At this point, the soiling is beyond the child's control, no matter how hard he tries. How doctors diagnose constipation The hallmark of constipation is a mass of hard stool in the colon and rectum. Doctors look for a history of hard, infrequent, large stools. (Sometimes the stools are runny, as noted above; sometimes a small bit of BM breaks off every day or so, so it appears that the child has regular BMs, but actually he never really empties his rectum.) Constipation often causes cramping, discomfort, or pain, but not always. In the physical examination, the doctor tries to feel the mass of stool in the abdomen (this can be difficult if the child is overweight or very ticklish). A rectal examination, although uncomfortable, is important to rule out a rare medical cause of constipation. The doctor may decide to hold off on this if it seems as though the examination would be traumatic to the child, and/or if other signs point to constipation. An X-ray of the abdomen can show the piled up stool in the colon. There is a small amount of exposure to radiation, but one, or even a few, abdominal X-rays are not known to cause harm (unless one is pregnant). Other tests that are used on occasion measure the time it takes stool to pass along the colon and the strength of muscular contractions in the rectum and anus, among other things. Most of the time, however, a good history and physical examination are all that is needed.
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