Bowel Management

Each year in the United States, an estimated 600 children, approximately one in every 4,000 babies, are born with malformations of the anus and/or rectum.

After the malformation has been repaired, the quality of life of children with anorectal malformations can be further improved through bowel management. The goal of a bowel management program is to help patients with fecal incontinence (the inability to voluntarily control the bowels) keep their bowels clean 24 hours per day and prevent problems that could lead to social isolation. The rate of success is high; 95% of patients who adhere to the Bowel Management Program are able to keep their bowels completely clean.

Each patient is different; therefore an individual, case specific plan must be established. In order to determine the best plan, the child is first evaluated to determine current colonic motility—how food moves through the colon. Patients with fecal incontinence can be classified into two major groups: those that suffer with constipation and those that tend to have diarrhea. Each group is managed completely differently.

First Steps:

  • The first step in the bowel management program is to perform a contrast enema study. The enema is performed using hydro-soluble material, also known as Hypaque, and is done without the child previously having bowel preparation. 
  • The x-ray test should never be done using barium. 
  • An x-ray picture should be obtained after the evacuation of the contrast material. 
  • Results will help the surgeon determine if the child has hypomotility (constipation) or hypermotility (diarrhea). 
  • Once the colonic motility is determined, a bowel management plan can be designed and implemented.

Hypomotility or Constipation:

  • The basis of the bowel management program for constipation is to teach the parents to clean the child's colon once a day by the use of a suppository, an enema or a colonic irrigation
  • Diet modifications or medications may not be necessary. 
  • The real challenge is only to find out the right enema capable of cleaning the colon completely. 
  • Soiling episodes or severe "accidents" occur by an incomplete cleaning of the bowel with feces that progressively accumulates into it.
Suppository:
  • Glycerin: Over the counter suppositories available, as well as liquid form, but consult with surgeon prior to giving.
Enema:
  • There are different types of solutions to use for enemas: there are some ready made solutions that can be bought in a drugstore or warm solutions that can be prepared at home based on water and salt. 
  • The use of the solutions has to be indicated by the physician who is following your child. 
  • The use of phosphate enemas (Fleet") is most convenient since it is already a prepared vial. However, pure saline enemas are often just as effective and some families find it easier and less expensive. 
  • Occasionally, children will complain of cramping with the “Fleet” enema but will have no complaints with the saline one. Children older than eight years of age or heavier than 65 pounds (30 kilograms) may receive one adult phosphate enema daily. 
  • Children between three and eight years of age or between 35 and 65 pounds (15 and 30 kilograms) may receive one pediatric phosphate enema a day. Children should never receive more than one phosphate enema a day because of the risk of phosphate intoxication. Children with impaired kdiney function should use “Fleet” enemas with caution. 
  • The phosphate enema administered on a regular basis should result in a bowel movement followed by a period of 24 hours of complete cleanliness. 
  • If one enema is not enough to clean the colon (as demonstrated by an x-ray, plus the fact that the child keeps on soiling), then the child requires a more aggressive treatment, and a saline enema is added, in addition to the phosphate. The recipe for normal saline is 1000 ml of tap water with 1 ½ teaspoons of table salt. DO NOT change this recipe; doing so could be harmful. 
  • The solution of the enema should be body temperature to decrease cramping. 
  • There is no magic formula for enema administration. After trial and error, you will determine what the correct amount of solution is for your child. The "right" enema is the one that can empty a child's colon and can let him / her stay clean for the following 24 hours.
Colonic or Rectal Irrigation:
  • Differs from enema because solution is meant to be placed and then removed almost immediately.
  • Use Normal Saline: 20ml/kg. Surgeon can determine exact amount for your child Using a red rubber catheter, the tip is lubricated with surgical lube and inserted into the anal opening. 
  • Connect the catheter tip syringe to the catheter and push in 20 mL of normal saline. 
  • Place syringe end of the catheter over the second basin and disconnect syringe from the catheter and let the fluid drip into the empty basin. 
  • Discard the soiled solution. 
  • Irrigations are repeated until you have used the amount your child’s doctor ordered or the fluid that comes out is clear. You may need to slide the tube in or out a little to get the fluid to drain out of the rectum completely. It is important to let the saline and stool drain out by itself before you put in more saline solution.
Foods to Avoid for Constipation
  • Apple Sauce 
  • Rice 
  • White Bread 
  • Bagels 
  • Boiled, Broiled, Baked Meat, Chicken, or Fish 
  • Soft Drinks 
  • Banana 
  • Pasta 
  • Pretzels 
  • Tea 
  • Potatoes

Hypermotility or Diarrhea

  • Children with diarrhea have an overactive colon and most of the time they do not have a reservoir. This means that even when an enema cleans their colon rather easily, the stool passes fairly quickly from the cecum to the descending colon and the anus. To prevent this, a constipating diet and/or medications to slow down the colon are recommended. 
  • It is important to determine if the patient has an overactive colon or if they are in fact constipated and stool is leaking around the impaction.
  • Medication to treat hypermotility: loperamide (Immodium): Your child’s surgeon will advise you on the dosage and frequency of administration. 
  • To determine the right treatment plan, the treatment starts with enemas (as described in the constipation section), a very strict diet, and a high dose of loperamide.
  • Most children respond to this aggressive management within 24 hours. 
  • The child should remain on a strict diet until clean for 24 hours for two to three days in a row. After this time, you may introduce a new food to your child and observe the effect on their stools. If the child soils after a particular food, it may be advisable to eliminate this food completely or be prepared for incontinence. 
  • Once the child is consistently continent, the loperamide dose may be adjusted on a trial and error basis to determine the appropriate amount for your child.
Foods to Avoid:
  • Milk or Milk Products 
  • Fats 
  • Fried Foods 
  • Fruits 
  • Vegetables 
  • Spices 
  • Fruit Juices 
  • French Fries 
  • Chocolate
Foods to Consume to Cause Constipation: 
  • Apple Sauce 
  • Rice 
  • White Bread 
  • Bagels 
  • Boiled, Broiled, Baked Meat, Chicken, or Fish 
  • Soft Drinks 
  • Banana 
  • Pasta 
  • Pretzels 
  • Tea 
  • Potatoes

Goals of a Bowel Management Program

  • Improve overall quality of life or limit disabilities related to anorectal malformations. 
  • Clean the colon and have it clean for 24 hours. 
  • Keys to success include timing, dedication, and collaboration with all of your child’s healthcare providers. 
  • More than 90 percent of the children who follow this program are artificially clean and dry for the whole day and can carry out a completely normal life and have a new sense of self-esteem and confidence based on an improved quality of life. 
  • Each child is different, therefore it is important to discuss with your doctor a plan that is designed specifically to meet your child’s needs.