Treatment of fecal impaction in children using combined polyethylene glycol and sodium picosulphate

Abstract

Background and aim: Polyethylene glycol (PEG) is the gold standard for fecal disimpaction in constipation. A regimen of PEG combined with the stimulant laxative sodium picosulphate (SPS) produced fecal disimpaction in chronically constipated children in the community, but it is unknown if it is effective for more severe constipation. To determine the stool output and effect of a combined PEG and SPS regimen on fecaloma in children with severe constipation and impaction.

Methods: Children with symptoms for a duration of ≥2 years, a palpable fecaloma, and enlarged rectum on X-ray (rectal: pelvic ratio > 0.6) were recruited from a tertiary hospital. Daily diaries recorded laxative dose, stool frequency, volume, and consistency (Bristol stool scale, BSS). Abdominal X-rays were taken on day 1 and day 8, and stool loading was assessed using the Leech score. Laxative doses were based on the child's age. The dose of PEG with electrolytes taken was 2-8 sachets (14.7 g/sachet) on days 1-2, reducing to 2-6 sachets on day 3. The SPS dose was 15-20 drops on days 2-3.

Results: Eighty-nine children (4-18 years) produced a large volume of soft stool (median/inter-quartile-range: 2.2/1.6-3.1 L) over 7 days. Stool volume on X-rays decreased significantly in the colon (P < 0.001). Fecalomas resolved in 40 of 89 children, while 49 needed a second high dose. Rectal:pelvic ratios did not change.

Conclusions: A combined high dose of PEG and SPS on days 1 and 2 was effective in removing the fecaloma in half of the children. Administering high doses for a longer period should be tested to provide outpatient disimpaction for severe fecalomas. Rectums remained flaccid after emptying.

Keywords: X‐rays; chronic constipation; laxatives; macrogol; polyethylene glycol.

Figure 1

Dose of laxatives and stool output per day. (a) Dose of polyethylene glycol (PEG) plus electrolytes taken. One sachet =14.7 g. (b) Dose of stimulant sodium picosulphate (SPS) drops taken. (c) Volume of stool (liters) produced. Stool volume was estimated by patients/parents. (d) Softness of stool estimated using the Bristol Stool Scale (BSS), where 1 is very hard and 7 is very soft. (n = 89, median, range).

Figure 2

Volume of stool on X‐rays. Volume of stool measured in X‐rays in (a) total colon and (b) each region: right colon (RC), left colon (LC); rectosigmoid (RS). Stool loading in X‐ray using the Leech Score in the (c) total colon and (d) each region. ****P < 0.0001, ***P < 0.001. Relationship of stool volume on X‐ray to Leech Score on (e) day 1 and (f) day 8. (n = 89, mean, SEM).

Figure 3

Rectal:Plevic ratio on day 1 and day 8. (n = 89, mean, SEM).

Figure 4

Relationship of X‐ray stool volume and stool output over 7 days. For total colon on (a) day 1 and (b) day 8. For rectosigmoid on (c) day 1 and (d) day 8.

Figure 5

Volume of stool on X‐ray in patients requiring one or two rounds of high‐dose laxatives to achieve disimpaction. (a,b) volume of stool in X‐ray in rectosigmoid (RS) for whole group (total) and for group disimpacted after one round of high‐dose laxatives (1 disimp, n = 40) or two rounds of high‐dose laxatives (2 disimp, n = 49). A: Median, range. (c,d) comparison of stool volume on X‐ray on day 1 and dose of Movicol taken over 7 days. (c) Group requiring one round of disimpaction and (d) group requiring two rounds of disimpaction.