The Bowel Management Program is a one-week intensive program for children who are unable to anticipate or control their bowel activity. The Bowel Management Program is useful for patients with:

• Anorectal malformations / imperforate anus

• Hirschsprung disease

• Fecal incontinence

• Idiopathic constipation

• Cloacal exstrophy

• Neurogenic bowel

• Neural tube defects

The basis of the bowel management program is to clean the colon with the use of enemas once a day and to decrease the motility of the colon with medication or diet to keep the patient clean for the following 24 hrs. It consists of

• Modification of the diet (if necessary)

• Medications (if necessary)

• Bowel cleaning (enemas)

Team and process

• The team involved in bowel management program includes pediatric surgeons and Pediatric Gastroenterologist. After reviewing clinical history, records and imaging ( like X-ray, colonic motility studies, Water soluble contrast enema etc.), the team will classify the children into one of the groups

  • kid with fecal incontinence and constipation (pseudo incontinence)

  • kid with fecal incontinence and diarrhoea (increased motility of gut)

• Bowel management of kids with fecal incontinence and constipation (pseudo incontinence)

  • Consists of finding, by trial and error, the specific type of enema capable of cleaning the colon of a specific patient, so that he is dry for 24h

  • Consists of rectal and colonic wash

  • No diet or drugs given

  • Takes advantage of decreased bowel motility in constipating children

• Bowel management of kids with fecal incontinence and diarrhoea (increased motility of gut)

  • Consists of finding, by trial and error, the specific type of enema capable of cleaning the colon of a specific patient, so that he is dry for 24h

  • Consists of rectal and colonic wash/enema 

  • Constipating diet and drugs are given.

  • There are some medications that are able to slow the motility of the colon. The use of these specific medications such as Lomotil or Immodium must be decided on with the physician.

• After starting treatment, most of the children will have daily or alternate day abdominal X-ray to determine how empty the colon is of stool. Depending upon the clinical and radiological results, adjustments to the treatment plan as appropriate will be done. The child and parents will be educated about the Bowel Management Program. Most of the children who complete this program will need to maintain a bowel management regimen for their entire lives. Further, when the child becomes older (8-12 years of age) and is embarrassed to receive enemas, creation of a continent appendicostomy (Malone procedure) may be done. It is an operation that consists in connecting the tip of the appendix to the deepest portion of their umbilicus and plicating the cecum around the appendix to create a one-way-valve mechanism that allows the passing of a catheter to deliver an enema while sitting on the toilet. Those without an appendix can undergo a neo-appendicostomy.

Results

• The result will depend upon dedication, timing and teamwork between the child, family and medical team. Each child’s regimen will be decided according to his or her specific needs. The child’s outcomes will also depend in part on the cause and severity of their condition. Some children may achieve bowel control only through diet and/ or medication while some will continue to need enemas. However, many of them are in normal underwear by the end of the week and are having better quality of life and self-esteem.