Constipation of functional origin in children (view through the prism of the Rome Consensus IV)

Constipation of functional origin in children (view through the prism of the Rome Consensus IV)

Functional disorders of the motility of the digestive organs, in contrast to those caused by structural (organic) changes in a particular organ, are associated with disturbances in its nervous and/or humoral regulation. The development of such diseases, including constipation of functional origin (FFO), is based on a disorder of the so-called “brain-gut axis”, dysregulation of the gastrointestinal tract (GIT) by the central nervous system (CNS). Various psycho-emotional and social factors thus influence the functional state of the digestive organs, in particular their motility, accelerating or slowing it down. On the other hand, under these conditions the reaction of the central nervous system to the ascending currents emanating from the gastrointestinal tract is also disrupted, which leads to its inadequate response. Disorders observed at the level of the gastrointestinal tract itself have also been identified, including from the enteric nervous system and the receptor apparatus, the state of which is influenced by the internal environment in the lumen of the gastrointestinal tract, intestinal microflora, the state of permeability of the epithelial barrier and many other factors.

All of these aspects are united by the so-called biopsychosocial model of functional disorders of the digestive system, according to which symptoms develop due to a combination of several known physiological determinants: impaired motility, visceral hypersensitivity, changes in mucosal immunity and inflammatory potential, including changes in the bacterial flora, as well as changes regulation of the axis of the central nervous system - the enteric nervous system as being influenced by psychological and sociocultural factors [1].

In the light of modern ideas about functional disorders of the digestive organs, they are defined as stable complexes of gastrointestinal symptoms that develop due to a combination of disorders of motility, visceral sensitivity and mucosal homeostasis in certain social and environmental conditions and/or in the presence of psychological personal characteristics, family predisposition [1] .

Over the past decades, specialists from all over the world have been joining forces to systematize and deepen their understanding of this group of diseases in order to develop a unified classification and general principles of diagnosis and treatment. Thus, in 1990, the first consensus on functional disorders of the digestive system was developed, called the Rome Consensus (Rome Criteria). In 2021, the next, fourth, revision of this consensus took place, replacing the Rome III criteria (2006). It should be noted that the changes made are largely clarifying in nature, and many fundamental provisions remain the same. As in the Rome III criteria, pediatric aspects are allocated to two classification sections (G and H), separating two age groups: G. Functional impairment in children from birth to 4 years of age, H. Functional impairment in children over 4 years of age. FTDs within the framework of the Rome Consensus are represented by irritable bowel syndrome (IBS) and functional constipation (FC). Also related to this problem are childhood dyschezia and non-retentive fecal incontinence.

Below are the relevant sections of the classification of functional disorders of the digestive organs within the framework of the Rome criteria III and IV, including those relating to adult patients accompanied by constipation (Table 1).

The diseases designated in the Rome criteria do not always coincide with the nosological units identified by the International Classification of Diseases, which must be used in everyday practice to code the diagnosis. Below are the disease codes with FFZ according to ICD-10.

ICD-10 CODES

• K 58. Irritable bowel syndrome (IBS)
• By 58.0. IBS with diarrhea
• To 58.9. IBS without diarrhea
• By 59.0. Constipation
• To 59.1. Functional diarrhea
• To 59.2. Neurogenic excitability of the intestine, not classified elsewhere
• To 59.8. Other specified functional bowel disorders
• To 59.9. Functional bowel disorders, unspecified

Diagnostic criteria for diseases and conditions associated with constipation of functional origin, in accordance with the Rome IV criteria (2016), are given in Table. 2.

IBS, as follows from the above consensus, can only be diagnosed in children over 4 years of age. By definition, IBS refers to functional disorders of gastrointestinal motility in the form of constipation and/or diarrhea, accompanied by abdominal pain. In the previous edition of the consensus, the fundamental difference between the concept of FF and the concept of IBS was the absence of pain in a patient with FF. The interpretation of the differences between IBS and FZ was preserved in the Rome IV criteria in the section devoted to intestinal motility disorders in adult patients. In addition, the latest consensus indicates that pain in IBS is somehow related to bowel movements. In the Rome III criteria, the wording was more categorical: “pain goes away after defecation.” The diagnostic criteria for IBS in the Rome III criteria for adults and children were similar, but have changed in the latest edition.

According to the Rome IV criteria, abdominal pain is not only a sign of IBS, but also does not contradict the diagnosis of FZ. This change is due to the fact that, according to studies, 75% of children of various ages with constipation experience abdominal pain [6]. Moreover, the 2021 criteria emphasize that in IBS with constipation, pain does not resolve with resolution of the constipation itself, and children whose pain resolves after defecation should be diagnosed with FZ, but not IBS. As for FZ, the leading symptom in this case is constipation, and abdominal pain (and bloating), although they may be present in the clinical picture, are still secondary symptoms.

Attention should also be paid to time aspects. A diagnosis of IBS can be made if abdominal pain combined with constipation occurs on at least 4 days per month for at least 2 months before diagnosis. In the case of FZ, signs should be observed at least once a week for at least 1 month [4, 5, 7].

You should also pay attention to the so-called “anxiety” symptoms, which exclude the diagnosis of FP [4, 5]:

• early onset of constipation (<1 month of age);
• passage of meconium more than 48 hours after birth in a full-term newborn;
• family history of Hirschsprung's disease;
• ribbon stool;
• blood in the stool in the absence of anal fissures;
• developmental delay;
• fever;
• vomiting bile;
• thyroid abnormality;
• severe bloating;
• perianal fistula;
• abnormal position of the anus;
• no anal reflex or cremasteric reflex;
• decreased lower limb muscle strength/tone/reflexes;
• a tuft of hair above the spinous process of the vertebra (an indirect sign of spina bifida);
• depression in the sacral area (indirect sign of spina bifida);
• deviation of the intergluteal groove;
• severe fear during examination of the anus;
• scars in the anal area.

The main goal in the treatment of FP is to ensure regular, painless bowel movements with a soft consistency, as well as to prevent the accumulation of stool.

This can be achieved as a result of a set of measures: education of parents and the child, behavior correction, daily use of laxatives and changes in diet. It must be emphasized that treatment of FP should be carried out differentially, taking into account the age of the child and the stage of FP: compensated, subcompensated and decompensated.

The first stage of treatment for FP is explanatory work with parents and children (older), when the possible causes and mechanisms of constipation are explained. Sometimes FFP can be caused by the peculiarities of the family environment or aggravated by them, so the help of a family psychologist may be needed.

Behavioral therapy is based on developing a toileting routine to achieve regular bowel movements. A prerequisite for effective defecation is to provide good foot support, which can be ensured by having a low bench in the toilet for the child to rest his feet on. If defecation is unsuccessful, the child should under no circumstances be punished, and, conversely, should be praised if successful [8].

Nutritional correction for constipation is a mandatory component of treatment: a diet including grains, fruits and vegetables is indicated [9]. Insufficient dietary fiber intake in the daily diet is a risk factor for constipation [8]. The United States National Academy of Sciences has proposed a dietary fiber intake of 14 g per 1000 kcal (15 g per day for a one-year-old child), and the Nutrition Committee of the American Academy of Pediatrics (AAP) - 0 .5 g/kg (up to 35 g/day) [10–12]. The Russian Society of Pediatric Gastroenterologists recommends the following calculation of dietary fiber intake: add 5–10 g per day to the child’s age ((5–10) + n, where n is the age in years, i.e. 6–11 g/day for a one-year-old child) [13]. It is recommended to exclude foods that delay bowel movement from the diet (Table 3). “Waste” food, pureed food, “food on the go”, “snacks” are not recommended. On the contrary, crumbly food, meat/poultry/fish “in pieces” are shown. A “voluminous” breakfast is required - to stimulate the “gastrocecal reflex”.

When eating coarse fiber, ensure adequate water intake. Only the simultaneous consumption of 25 g of plant fiber and at least 2 liters of liquid per day accelerates intestinal transit and softens stool [14].

Drug (supportive) therapy

Painless stools of soft consistency are achieved with the help of laxatives. When developing treatment tactics for FD, an individual treatment program taking into account the premorbid background and concomitant pathology is extremely important. The main problem in the treatment of FD in children is age restrictions when using laxatives. Along with laxatives, the administration of normokinetics (trimebutine), pre- and probiotics, as well as antispasmodics and choleretic agents in some patients is effective.

In domestic practice, among all groups of laxatives used in pediatric practice, preference is given to drugs with an osmotic effect. Their main mechanism of action is to soften the stool by retaining water, which facilitates the transport of chyme and makes defecation less difficult. At the same time, the volume of stool increases, intestinal motility is stimulated, and transit is normalized. This group of drugs includes drugs based on lactulose, lactitol, and macrogol. A special feature of lactulose and lactitol is their prebiotic effect. Antispasmodics of plant origin, which have an effect on the secretion of gastric juice and intestinal motility, can be considered as additional means of treating FFP [9]. Clinical experience in the treatment of constipation indicates the advisability of using choleretic drugs in the complex treatment of constipation. The general principles of differentiated therapy for FP, depending on the nature of the pathological process, are given in Table. 4.

Thus, constipation of functional origin, being a common pathology of childhood, requires attention and often painstaking differential diagnosis. Timely diagnosis of functional disorders of the digestive organs and their treatment are necessary to prevent the development of complications and their evolution into organic pathology.

Literature

1. Drossman DA The functional gastrointestinal disorders and the Rome III process // Gastroenterology. 2006; 130:1377–1390.
2. Drossman DD, Corazziari E, Delvaux M et al. Rome III: The Functional Gastrointestinal Disorders. 3rd Edition. VA, USA: Degnon Associates, Inc.; 2006.
3. Drossman DA, Hasler WL Rome IV - Functional GI Disorders: Disorders of Gut-Brain Interaction // Gastroenterology. 2016; 150(6):1257–1261.
4. Hyams JS, Di Lorenzo C., Saps M., Shulman RJ, Staiano A., van Tilburg M. Childhood Functional Gastrointestinal Disorders: Child // Adolescent. Gastroenterology. 2016; 150(6):1469–1480.
5. Benninga S., Nurko MA, Faure C., Hyman PE, James Roberts I. St., Schechter NL Childhood Functional Gastrointestinal Disorders: Neonate/Toddler // Gastroenterology. 2016; 150(6):1443–1455.
6. Burgers R., Levin AD, Di Lorenzo C. et al. Functional defecation disorders in children: comparing the Rome II with the Rome III criteria // J Pediatr. 2012; 161: 615–620 e1.
7. Lacy BE, Mearin F., Chang L., Chey WD, Lembo AJ, Simren M., Spiller R. Bowel Disorders // Gastroenterology. 2016; 150(6):1393–1407.
8. Inan M., Aydiner C., Tokuc B. Factors associated with childhood constipation // J Paediatr Child Health. 2007; 43: 700–706.
9. Rasquin A., Di Lorenzo C., Forbes D. Childhood functional gastrointestinal disorders: Child/adolescent // Gastroenterology. 2006; 130:1527–1537.
10. Morais MB, Vitolo MR, Aguirre AN, Fagundes-Neto U. Measurement of low dietary fiber intake as a risk factor for chronic constipation in children // J Pediatr Gastroenterol Nutr. 1999; 29: 132–135.
11. Lee WT, Ip KS, Chan JS, Lui NW, Young BW Increased prevalence of constipation in pre-school children is attributable to under-consumption of plant foods: A community-based study // J Pediatr Child Health. 2008; 44: 170–175.
12. Castillejo G., Bulló M., Anguera A., Escribano J., Salas-Salvadó J. A controlled, randomized, double-blind trial to evaluate the effect of a supplement of cocoa husk that is rich in dietary fiber on colonic transit in constipated pediatric patients // Pediatrics. 2006 Sep; 118(3):e641–8.
13. Khavkin A. I., Fayzullina R. A., Belmer S. V., Gorelov A. V., Zakharova I. N., Zvyagin A. A., Kornienko E. A., Nizhevich A. A., Pechkurov D. V., Potapov A. S., Privorotsky V. F., Rychkova S. V., Sheina O. P. Diagnosis and tactics of managing children with functional constipation (Recommendations of the Society of Pediatric Gastroenterologists) // Issues of Pediatric Dietetics. 2014; 12 (4): 49–63.
14. Carbohydrate and dietary fiber. In: Kleinman RE, ed. Pediatric Nutrition Handbook, 6th Edition, Community on Nutrition. American Academy of Pediatrics 2009; 104.

S. V. Belmer*, 1, Doctor of Medical Sciences, Professor A. I. Khavkin*, Doctor of Medical Sciences, Professor D. V. Pechkurov**, Doctor of Medical Sciences, Professor

* Federal State Budgetary Educational Institution of the Russian National Research University named after. N. I. Pirogova Ministry of Health of the Russian Federation, Moscow ** Federal State Budgetary Educational Institution of Higher Education SamSMU Ministry of Health of the Russian Federation, Samara

1 Contact information

Functional constipation: recommendations for diagnosis and treatment

Constipation is considered chronic (more than 48 hours) delay in bowel movement or difficulty in defecation while maintaining normal bowel movements. Constipation is considered functional if there is no connection with known genetic, structural or other changes in the intestine. In Western countries, chronic constipation is widespread, affecting between 2% and 27% of the population [13]. Constipation occurs in approximately 12% of the world's population, while residents of America and Southeast Asian countries suffer from it 2 times more often than Europeans (17.3 and 8.75%, respectively) [4]. These numbers are not true because many patients do not go to the doctor, hoping that constipation will resolve on its own (not counting those who are dissatisfied with the results of treatment). There are no similar statistics in Russia, but the average figures published in various reports are approximately the same as those presented. The widespread prevalence of constipation has given grounds to classify this disorder as a disease of civilization. Normal stool frequency is an individual indicator for each person, while it is generally accepted that in practically healthy people the normal frequency of stool ranges from 1–3 times a day to 1 time in 3 days (5–7% of those examined) [10] . As a rule, such features are hereditary. In this work, we will consider mainly functional constipation (FC), which is the competence of therapists and gastroenterologists. Organic constipation is usually an acute situation within the competence of surgeons. When initially considering the nature of constipation (physical or organic), we must use international criteria (Rome III criteria, 2006), according to which 2 or more of the following signs must be present: - rare evacuation of intestinal contents (less than 3 bowel movements per week); – passing a small amount of feces during bowel movements (<35 g/day); – passage of dense, dry feces, fragmented like “sheep”, traumatic the area of ​​the anus (the sign should occur more often than in 1/4 of bowel movements); – a feeling of blockage of contents in the rectum when pushing (anorectal obstruction); – at least 25% of the time of defecation is accompanied by straining; sometimes there is a need to remove contents from the rectum using a finger, supporting the pelvic floor with fingers (more often than in 1/4 of bowel movements). Constipation is considered functional and chronic if symptoms have been present for at least 6 months. until the time of diagnosis and persist for at least 3 months, not necessarily continuous, there are no sufficient criteria for diagnosing irritable bowel syndrome, independent bowel movements rarely occur without the use of laxatives. The main pathogenetic mechanism for the development of FZ is a violation of the motor function of the colon, associated with a decrease in the rate of movement of intestinal contents in the absence of anatomical abnormalities (slow - transit constipation or inert colon). Among other factors that form FZ, one can highlight: a) increased absorption of water in the colon, b) the patient’s inability to perform a bowel movement, c) the patient’s lack of urge to defecate, which indicates a violation of the sensitivity of the receptor apparatus of the anorectal zone of the intestine, which performs the storage function and evacuation of feces. In addition to chronic ones, there are “temporary” constipations, the causes of which are: – changes in living conditions; – change in the nature of nutrition and food; – change in comfortable conditions for defecation (“travelers’ constipation”); – emotional stress; – pregnancy (with a natural change in hormonal status); – bed rest; – taking medications that change colon motility. Identification of this group of constipation is of great clinical importance, since understanding the cause and explaining it to the patient (especially with an anxious and suspicious character) can relieve psycho-emotional stress and resolve the situation as a whole. Since the chronic constipation in question is functional in nature, the diagnosis is made by the method of differential diagnosis with the exclusion, first of all, of diseases (or clinical situations) that occur with constipation and are associated with: - lifestyle (insufficient consumption of dietary fiber, small amount of food and fluid intake, low physical activity); – with the influence of external factors (side effects of medications (iatrogenic constipation)); – with endocrine and metabolic disorders (hypothyroidism, hypercalcemia, porphyria, amyloidosis); – with neurological factors (parkinsonism, multiple sclerosis, impaired spinal cord function, impaired parasympathetic innervation from the sacral plexus, autonomic neuropathy in diabetes mellitus (intestinal pseudo-obstruction syndrome)); – with psychogenic factors (emotional overload, stress, depression, anorexia, obsessions with “inner purity”); – with gastroenterological diseases (impaired intestinal patency as a result of stricture, obstruction by a tumor or foreign body, external compression (adhesive disease), congenital aganglionosis (Hirschsprung's disease), dolichosigma, myopathy, neuropathy of various origins, systemic scleroderma with intestinal damage, irritable bowel syndrome ( variant with a predominance of constipation), helminthic infestation; - with pathology of the anorectal organs (stenosis of the anal canal, weakness of the pelvic floor, prolapse of the perineum, asynergy of the pelvic floor, large rectocele, rectal prolapse, rectal ulcer) .

Examination of a patient with constipation should include a thorough questioning and examination, assessment of lifestyle, collection of a medical history, digital examination per rectum, examination of general and biochemical blood tests, and coprograms.
The data obtained determine the algorithm for further examination. Identification of “symptoms of anxiety” (asthenic manifestations, fever, weight loss, anemia, increased ESR, presence of blood in the stool) makes it necessary to conduct an endoscopic/x-ray examination of the intestine. This part of the diagnostic process helps to carry out a differential diagnosis with secondary and situational forms of constipation, and the diagnosis itself, taking into account the variety of causes and mechanisms of development of constipation at the patient’s first visit, should be stage-by- Stage 1:
• Assessment of clinical data (correspondence of the patient’s complaints accepted criteria for constipation).
• X-ray examination of the intestine, allowing to assess the anatomical state of the colon (either its normal structure or positional anomalies, idiopathic megacolon, tumors, strictures, Hirschsprung's disease, adhesive disease). Stage 2:
• Colonoscopy with biopsy of the mucous membrane to clarify or exclude structural changes.
• Assessment of the condition, including functional, of other organs and parts of the gastrointestinal tract, endocrine parameters affecting intestinal motility. For women, an examination by a gynecologist is required to determine the position of the uterus. After establishing the status, the patient is transferred to a specialist, and functional intestinal disorders are considered secondary. Stage 3:
• Special research methods to assess the motor-evacuation function of the colon, the condition of the obturator apparatus of the rectum (electromyography, isotope study, anal manometry, study of microbial status, short-chain fatty acids (SCFA) in feces, study of electrolyte balance) . Completing the examination program will answer the main question: is constipation caused by organic pathology (and then the patient is referred to specific specialists) or is it functional in nature, and then it will be dealt with by either a therapist or a gastroenterologist. Since the diagnosis of functional diseases today is made by exclusion, the implementation of an examination program is mandatory. And only after the diagnosis has been made, the forms that are subject to surgical treatment are determined, an endocrinologist, gynecologist, and psychotherapist are involved in treatment, and long-term treatment is carried out with a therapist or gastroenterologist.

Treatment

Basic principles of treatment for physical disease: – after clarifying the nature of nutrition, a diet correction is carried out (the volume and nature of nutrition change, water balance is regulated); – lifestyle correction, mainly physical activity (in accordance with age and intestinal activity); – treatment of the underlying disease that caused constipation or contributed to its occurrence; – correction of negative drug effects (drug withdrawal, dose change, replacement with drugs of another pathogenetic group); – physiotherapeutic procedures (in the absence of contraindications); – normalization of motor function of the colon (prokinetics for hypokinesia or antispasmodics for hyperkinesia of the colon); – use of laxatives. Speaking about diets, it should be remembered that the reasons for the formation of physical fitness in young children are: – transfer to artificial feeding; – the formation of food allergies (primarily to cow’s milk proteins, which is often the cause of constipation in adults); – imperative education of toilet skills (in children 1–2 years old); – painful bowel movements with the development of “potty sickness”; – start visiting a child care facility; – lack of comfortable conditions for defecation. These provisions must be remembered and considered important when choosing treatment for constipation in children. Dietary recommendations for an adult patient with constipation are based on the motor function of the colon. Thus, with hypomotor dysfunction, the diet is formed according to the type of “slag” load. The emptying of the intestines is promoted by: vegetables, fruits (bananas, apples), berries, mostly raw - at least 200 g/day; prunes or dried apricots (8–12 berries); vegetable oil (olive, corn) – 1–2 tbsp. l. on an empty stomach (it is better to stir in kefir and take at night); buckwheat, oatmeal, barley, pearl barley porridge; honey - 1 tbsp. l. 2–3 rubles/day; wheat bran (included in the “Zdorovye”, “Barvikhinsky”, “Doctorsky” bread varieties). The amount of fluid should be increased to 1.5–2 l/day. It is advisable to drink 1-2 glasses of cold water (fruit juice) in the morning on an empty stomach with the addition of 1 tbsp. l. honey or xylitol. The following should be excluded from the diet: rice, semolina porridge, pasta, vermicelli, mashed potatoes, jelly, since these products inhibit bowel movements. Regardless of the predominant type of colon motility, dietary fiber is used in the diet (bran, microcrystalline cellulose, mucofalk - plantain seed peel, psyllium - plantain, seaweed, dietary supplements with a high content of soluble and insoluble fiber). A prerequisite for the use of dietary fiber is maintaining an increased water balance, since they adsorb water, increase the amount of bacterial flora, fecal mass and change the myoelectric activity of the intestine, which balances the propulsive and tonic contractions of the muscles of the colon. With the destruction of dietary fiber, the formation of SCFA increases, which are used as a trophic substrate for enterocytes (acetate, propionate). In elderly and senile patients with heart failure, these recommendations should be used with caution. For hypermotor dysfunction, the diet is more gentle. Vegetables are consumed boiled, and much attention is paid to vegetable fats. Wheat bran is prescribed in gradually increasing doses to the optimal amount that maintains the therapeutic effect. Recommendations for lifestyle correction include no morning rush, a voluminous breakfast, a comfortable toilet, a comfortable position in the toilet (with knees pulled up, legs on a small bench), morning exercises (Valsalva movement, imitation of cycling, self-massage of the abdomen). Drug therapy is aimed primarily at regulating motor skills. It should be remembered that the development of constipation can be caused by taking medications that inhibit motility (anticholinergics, antispasmodics with a wide spectrum of action, histamine receptor blockers, etc.). You should carefully collect a medical history and refuse some groups of drugs, replace others or reduce the dose. After the initial pharmacotherapy has been corrected (secondarily affecting colon motility) and the type of motility disorder has been established (hypotension, hypertension, mixed type motility disorder), gastrointestinal motility regulators are prescribed. The following representatives of this group were used at different periods of time: domperidone, itopride, trimebutine. All of them in average therapeutic doses during a course of treatment were effective in 70–90% of patients. Since they all belong to the receptor group, during long-term treatment the resulting effect disappears, which requires replacement with a motor regulator with a different mechanism of action. All laxatives can be divided into 3 main groups: 1. Increasing the volume of intestinal contents: – dietary fiber, – hydrophilic colloids (macrogols), – osmotic: oligosaccharides (lactitol, lactulose, duphalac); alcohols (sorbitol, glyceryl); saline laxatives (magnesia, Glauber's salt, etc.). 2. Stimulating: – anthraglycosides (preparations of senna, buckthorn, rhubarb), – diphenylmethane derivatives (bisacodyl, dulcolax), – sodium picosulfate (Guttasil). 3. Softening feces (vaseline and other mineral oils). Each of these groups of drugs has its own advantages and disadvantages, and there must be “its own” group of patients, characterized by a certain type of motility disorder, age, concomitant pathology, the nature of the microflora disorder, etc. Thus, hydrophilic colloids have a moderately pronounced osmotic effect and increase the volume intestinal contents. Their disadvantages are a slowly developing effect and severe intestinal hypotension. Drugs in this group are not indicated for patients with proctogenic constipation. Osmotic laxatives (sorbitol, mannitol, glycerin) and saline laxatives act at the level of the small intestine and promote a large release of fluid into the intestinal lumen, which may result in diarrhea, tissue dehydration and loss of electrolytes. Currently, they are used in complex bowel preparation for examination. Oligosugars (lactose and its derivatives) act only in the colon, have a double effect: they increase volume and are bifidogenic and lactogenic prebiotics, stimulating bacterial growth. Stimulants have a quick effect (sometimes unpredictable), addiction to them quickly develops, and adverse events are possible, especially in patients with cardiovascular pathology. Having a limited period of use, many drugs require careful medical supervision. Thus, metabolites of the drug senna, with long-term use, accumulate in the intestinal mucosa and neurons of the ganglion plexuses, which leads to degenerative changes in smooth muscles with the development of an “inert colon.” Metabolites of anthraglycosides are hepato- and nephrotoxic, have a mutagenic effect and should not be used for a long time, much less permanently. Sodium picosulfate (Guttasil) has a number of advantages over drugs from its own and other groups. This is a contact laxative of the triariamethane group, which is activated only in the colon under the action of bacterial sulfatases. The drug stimulates the sensitive nerve endings of the mucous membrane, enhancing motor skills. During a course of treatment, it stimulates the growth and metabolic activity of normal (obligate) intestinal microflora. It has a mild, predictable effect, which gives the patient the opportunity to plan his day. It is also convenient to have two forms of release: drops and tablets. Dosage regimen: a) drops: – adults and children over 10 years old – 13–27 drops; – children from 4 to 7 years old – 7–13 drops; – children under 4 years old – 2 drops per 3 kg of weight; b) tablets (7.5 mg): – adults and children over 10 years old – 1 tablet per day, course – 30 days. Limiting ourselves to the information presented [5–7], it should be noted that the use of laxatives for constipation is far from a simple matter, and the decision to use them should not be the beginning of pharmacotherapy, but the end of its choice. The treatment itself should be carried out only under the close supervision of a therapist or gastroenterologist. Violation of any principle of treatment of constipation on the part of the doctor or the patient leads to dissatisfaction of the patient using laxatives; the following may be noted: – weak (insufficient) effect; – excessive effect (uncontrollable stool); – “escape” of the effect (return of constipation), etc. All this leads to the beginning of a new cycle of work with the patient (examination, testing of doses, changing laxatives, combined treatment option). It is much easier to treat with laxatives under the supervision of a doctor, then the effectiveness of this therapy will be much higher. Successful treatment of constipation lies in identifying the causes of its occurrence and choosing the right treatment program. Timely diagnosis is the key to preventing the progression of colon pathology and the functionally dependent pathology of the gastrointestinal tract.