Clinical Consult: Evaluation and treatment of encopresis

Encopresis imageConstipation is a common presentation in pediatric primary care. A diet rich in fiber and fluids, exercise and extra time for bowel movements is the first line of treatment for the condition that affects three percent of children worldwide.

But when constipation leads to encopresis, children suffering with fecal soiling not only experience physical discomfort, it may impact a child’s psychological or social wellbeing.

Boston Children’s Hospital’s gastroenterologist Leonel Rodriguez, MD, MS, with the Division of Gastroenterology, Hepatology and Nutrition, tackles this issue and offers tools to evaluate and manage encopresis in the primary care setting.

Diagnosing encopresis

According to Rodriguez, encopresis is a clinical diagnosis and obtained via physical exam and a thorough history.

“When you do a physical exam and feel a mass, the child probably has fecal impaction,” he says. “Then you know why the child is having accidents.”

He also says there is usually no need for x-rays. “It’s important that the diagnosis is clinical and not by x-ray because it is not uncommon for a patient to have abdominal pain, get an X-ray and we see stool there but that does not mean it is the cause,” he says.

Treatment options

  • Demystifying the diet. Many believe a diet rich in fiber is the most important treatment for encopresis. Although diet plays an important role in a child’s digestive function, children with encopresis need more.

“Pediatricians understand diet plays an important role but once you get to the point of significant encopresis, diet isn’t enough and most times we need to introduce other medications,” he says.

Medication is recommended to accelerate the bowel transit and expedite colon recovery process. Note: It’s important for clinicians to stress to parents and caregivers that these products should ONLY be used at the recommendation of a trained health care provider.

  • Start with the softeners. Rodriguez suggests lactulose (a non-absorbable sugar) or Miralax, because they are designed to soften stool. “We need to make the stool soft so they don’t have large, hard bowel movements that promote withholding behavior,” he says.

Both medications are easy to give to patients, not too difficult to titrate, are commercially available and consider safe.

“Some children do better on lactulose than Miralax and vise versa,” Rodriguez adds. “Or you can potentially switch in between these medications within the same category depending on tolerance and preference.”

  • Mineral oil and other lubricants: Rodriguez suggests shying away from using mineral oil in patients with respiratory problems due to potential side effects.We don’t use lubricants such as mineral oil because there is the potential for a child to aspirate if vomiting which increases the risk for pneumonia,” Rodiguez says.
  • Stimulants: This form of treatment is used as an “add-on” medication and typically recommended for patient that doesn’t respond to softeners. “We rarely use stimulants as a single medication,” Rodriquez says. “Stimulants are given to patients who are not quite emptying completely and a stimulant will promote bowel emptying.”

Treatment is long term

Once you reach the point of having encopresis, it is a chronic problem and will not be solved in a few weeks. “We treat some patients at Boston Children’s over a four-to-six month period until things get better,” Rodriguez adds.

The goal is to recover bowel and colon function and find the child’s baseline. Once this has been achieved, slowly wean the child off the medication regimen. “We don’t abruptly stop the medication because the encopresis will likely come back,” he says.

Realistic expectations

Everyone has their own “normal,” and not all of us are designed to go to the bathroom everyday. It is important for patients and families have realistic expectations.

“If the child is having soft bowel movements, no accidents and going three-to-four times a week, that’s enough,” Rodriguez says. “We don’t have to over medicate to make sure they go once a day.”

When to refer a patient to a specialist

If the patient exhibits red flags including significant abdominal distention despite appropriate use of after stool softener or stimulants, and the child is still passing large, hard bowel movements, Rodriguez recommends the child be seen by a gastroenterologist to make sure there isn’t an anatomical issue.

“If the child is not responding to medication, I suggest sending them to a gastroenterologist to make sure there isn’t a colon motility problem, with the anal sphincter or other issue,” he says.

Psychological affects of encopresis

If a child is soiling, especially if they are having accidents at school, the child may become emotionally upset leading to feelings of shame and embarrassment.

“Encopresis not only impacts the child, it impacts the whole family because the parents get embarrassed and they often reprimand the child,” Rodriguez says. “That is why is important to establish a proper treatment in a timely fashion to avoid further psychological consequences.”

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