Comparing Treatments for Intractable Functional Constipation

Peter Lu, MD

Peter Lu, MD, MS, pediatric gastroenterologist at Nationwide Children’s Hospital

US News Badge GastroenterologyUS News Badge GastroenterologyMost kids respond to traditional treatments for constipation, including behavioral interventions and laxatives, but a sizable number continue to have problems with intractable constipation that can lead to fecal incontinence.

For these children, treatment options include minimally invasive surgical procedures such as antegrade continence enemas (ACE) and sacral nerve stimulation (SNS). However, there is little data comparing these procedures and guidelines for their use are lacking, leading to variation in treatment practices.

In a new study, researchers compared the efficacy and safety of ACE and SNS in children with intractable functional constipation. The objective was to compare the treatments to help clinicians better decide on the best option for each patient.

The team, led by Peter Lu, MD, MS, a pediatric gastroenterologist at Nationwide Children’s Hospital, found that both ACE and SNS led to durable improvement of functional constipation in children, although the two treatments had different effects on specific symptoms.


“It was clear from our data that SNS works well for stool accidents, even though it did not make a huge difference for other factors, like bowel movement frequency and abdominal pain,” says Dr. Lu, also an assistant professor of Clinical Pediatrics at The Ohio State University College of Medicine. “ACE helped with stool accidents, though not to the same degree as SNS, but was better for making bowel movements more regular and decreasing abdominal pain.”

Dr. Lu and his colleagues say this study is the first step toward being able to decide on an ideal treatment option based on a child’s symptoms.

“Our takeaway from this study is that if the child’s main symptom is fecal incontinence, and especially if they have urinary symptoms too, SNS may be a good option,” Dr. Lu says. “Whereas if fecal incontinence is secondary to not being able to go and having a lot of pain, ACE may be the better option.”

Dr. Lu says that larger, randomized, prospective studies are needed to gather more evidence for the optimal uses of these two treatments. Future studies could also examine other treatment options considered for these patients, such as surgically removing part of the colon.

“This research is only possible with a multidisciplinary team like the one here at Nationwide Children’s, comprised of people from gastroenterology, surgery and urology who are passionate about these problems and understand the impact they can have,” Dr. Lu says. “These are kids who deserve our attention and care.”

Vriesman MH, Wang L, Park C, Diefenbach KA, Levitt MA, Wood RJ, Alpert SA, Benninga MA, Vaz K, Yacob D, Di Lorenzo C, Lu P. Comparison of antegrade continence enema treatment and sacral nerve stimulation for children with severe functional constipation and fecal incontinence. Neurogastroenterology and Motility. 2020;e13809.

A Decade of Remarkable Transformation: Gastroenterology, Hepatology and Nutrition

The past decade has seen expansion in advanced neuromodulation therapies (gastric pacing, modulation of sacral, posterior tibial and auricular nerves) to help children with multiple types of functional and motility problems. The division has also instituted more than 20 quality improvement initiatives aimed at improving outcomes and has published results for many of them.

  • 2011: First Rumination Syndrome Treatment Program in Pediatrics
  • 2012: First Use of Wireless Motility Capsule in Pediatric Patient
  • 2012: Carlo Di Lorenzo, MD, is NASPGHAN President-Elect
  • 2013: Center For Colorectal & Pelvic Reconstruction is World’s First to Formally Integrate Clinical and Surgical Specialties
  • 2017: Liver Transplant Center Launched
  • 2018: NASPGHAN Honors John Barnard, MD, With Harry Shwachman Award for Lifelong Contributions