Occult constipation masking as irritable bowel syndrome with predominant diarrhea in Bangladeshi children

Table 1 Rome IV criteria for the diagnosis of functional constipation and irritable bowel syndrome

Diagnostic criteria for functional constipation

Must include 2 or more of the following occurring at least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of irritable bowel syndrome:

2 or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years

At least 1 episode of fecal incontinence per week

History of retentive posturing or excessive volitional stool retention

History of painful or hard bowel movements

Presence of a large fecal mass in the rectum

History of large diameter stools that can obstruct the toilet

In addition, the symptoms are insufficient to fulfill the diagnostic criteria of irritable bowel syndrome.

Diagnostic criteria1 for IBS

Must include all of the following:

1 Abdominal pain at least 4 days per month associated with one or more of the following:

Related to defecation

A change in frequency of stool

A change in form (appearance) of stool

2 In children with constipation, the pain does not resolve with resolution of the constipation (children in whom the pain resolves have functional constipation, not irritable bowel syndrome)

3 After appropriate evaluation, the symptoms cannot be fully explained by another medical condition

1Criteria fulfilled for at least 2 months before diagnosis

Diagnostic criteria for IBS subtypes

IBS with predominant constipation

More than one-fourth (25%) of bowel movements with Bristol stool form types 1 or 2 and less than one fourth (25%) if bowel movements with Bristol stool form types 6 or 7

IBS with predominant diarrhea

More than one-fourth (25%) of bowel movements with Bristol stool form types 6 or 7 and less than one fourth (25%) if bowel movements with Bristol stool form types 1 or 2

IBS with mixed bowel habits

More than one-fourth (25%) of bowel movements with Bristol stool form types 1 or 2 and more than one fourth (25%) of bowel movements with Bristol stool form types 6 or 7

IBS unclassified

Patients who meet diagnostic criteria for IBS but whose bowel habits cannot be accurately categorized into 1 of the 3 groups above

¹Diagnostic criteria for irritable bowel syndrome.

IBS: Irritable bowel syndrome.

Table 2 Comparison of symptoms before and after treatment, n (%)

Symptoms	Before treatment	After treatment	P value
Abdominal pain	49/49 (100)	2/49 (4.1)	P < 0.0011
Stool frequency (> 3/day)	49/49 (100)	2/49 (4.1)	P < 0.0011
Bristol type 6 or 7	49/49 (100)	2/49 (4.1)	P < 0.0011
Anorexia	29/49 (59)	2/49 (4.1)	P < 0.0011
Nausea	15/49 (30)	2/49 (4.1)	P < 0.0011
Mucoid stool	10/49 (20)	0/49 (0)	P < 0.011
Bed wetting	5/49 (10)	0/49 (0)	P = 0.0631

¹McNemar’s test.

Table 3 Occult constipation, treatment response, and cost comparison, n (%)

Variable	Result	P value
Occult constipation in unresponsive IBS-D (n = 54)	Yes: 49 (90.7)	P < 0.0011
	No: 5 (9.3)
Overall response after treatment (n = 49)	Good response: 44 (89.8)	P < 0.0011
	Satisfactory: 2 (4.1)
	No response: 2 (4.1)
	Lost to follow-up: 1 (2.0)
Presumptive treatment cost	Conventional method: 25000 BDT	98.4% cost reduction
	Our model: 400 BDT

¹χ² test.

IBS-D: Irritable bowel syndrome with diarrhea.