Downloaded 15 times
Uploaded byAravind A
Constipation
This document discusses constipation in children. It defines constipation and provides Rome criteria for diagnosing it in infants/toddlers and older children. Constipation is common and usually functional without an organic cause. Treatment involves education, disimpaction with laxatives, prevention through diet/behavior changes and sometimes medications, and follow up. Functional non-retentive fecal incontinence is also discussed.
More Related Content
Constipation
- 1. CONSTIPATION DR ARAVIND A DNBPOSTGRADUATE
- 2. OVERVIEW • DEFINITION • PATHOGENESIS •CAUSES AND RISK FACTORS • CLINICAL EVALUATION AND DIAGNOSIS • LABORATORY AND RADIOLOGIC INVESTIGATIONS • TREATMENT • FOLLOW UP AND PROGNOSIS
- 3. Introduction • Constipation andfecal incontinence represent common problems in children. • The stool frequency gradually declines from more than 4/day during the 1st week of life to one or two per day by the age of 4 years. • From 5 yrs of age, majority of children pass stools daily or every other day without straining or withholding
- 4. Definition • Constipation isdefined by ROME criteria. • Different diagnostic criteria for constipation in infants and toddlers upto 4 years and for childhood constipation in older children and adolescents. • FECAL INCONTINENCE: involuntary loss of stool into the underwear in a child older than age of 4 years.
- 5. Fecal incontinence • Canbe classified as constipation associated fecal incontinece –overflow incontience and functional nonretentive fecal incontinence(FNRFI). • Constipation related is more common. • Can also be classified as primary or secondary • FRFI and FNRFI both differ in etiology and management.
- 6. Rome criteria forPediatric Functional Constipation Two or more criteria for at least 1 month in infants upto 4 years. Two or more symptoms for atleast once per week for atleast 2 months in children >4 years • Two or more defecations per week • Atleast one episode of fecal incontinence per week • History of retentive posturing or excessive stool retention • History of painful or hard bowel movements • Presence of large fecal mass in the rectum • History of large diameter stool that may obstruct the toilet • Additional criteria: without fulfilling irritable bowel syndrome criteria.
- 7. Rome criteria forpediatric FNRFI Diagnostic criteria must include all of the following in children at least 4 years of age for atleast 2 months prior to diagnosis • Defecation into places inappropriate to the social context at least once per month. • No evidence of an inflammatory, anatomic, metabolic or neoplastic process that explains the symptoms • No evidence of fetal retention
- 8. EPIDEMIOLOGY • 3% ofvisits to pediatricians • 25% of visits to pediatric gastroenterologist • Functional/non organic is the most common • Organic is rare(except in infancy) • Worldwide prevalence of fecal incontinence varies from 0.8% to 7.8%
- 9. Pathogenesis • Multifactorial • Morethan 90% of children – no obvious organic cause is found – functional • Can occur at any age , but children vulnerable are infancy(during the introduction of cereals and other solids), toddlers(during toilet training), older children. • Constipation in newborn and early infancy – organic cause or congenital disorder.
- 10. Organic causes ofconstipation • Intestinal causes – hirschsprung disease, anorectal malformation, neuronal intestinal dysplasia • Neuropathic conditions – spinal cord abnormalities, spinal cord trauma, neurofibromatosis, tethered cord syndrome • Metabolic, endocrine causes – hypothyroidism, DM,hypercalcemia, hypokalemia, vitamin D intoxication • Drug induced – opioids, anticholinergics, antidepressants • Other causes – anorexia nervosa, sexual abuse, cystic fibrosis, dietary protein allergy, scleroderma
- 11. Passage of hard,painful or frightening bowel movement Purposeful subconscious stool withholding – fear of defecation (retentive posturing) Rectal mucosa absorbs the water from the fecal mass Retained stools become progressively more difficult to evacuate Vicious cycle of stool retention for a long period Untreated for a long period, rectal wall becomes stretched Development of megarectum Overflow incontinence, loss of rectal sensation and loss of normal urge to defecate
- 12. Fecal incontinence -pathogenesis Stool withholding - constipation Progressive accumulation of feces Hardening of fecal mass Feces seep between the fecal mass and rectal wall and escape thro the anal canal when sphincters are relaxed Stains the underwear – fecal incontinence Nocturnal incontinence – indicator of severe accumulation of feces in the rectum
- 13. FNRFI • Pass stoolsin inappropriate places. • Majority have complete evacuation of bowel, not just staining of underwear. • Colonic transit time studies, rectal compliance and sensitivity thresholds are normal.
- 14. Organic causes ofFI • Repaired anorectal malformation • Post surgical HD • Spinal dysraphism • Spinal cord trauma • Spinal cord tumor • Cerebral palsy • Myopathies of pelvic floor and external anal sphincter
- 15.
- 17. Clinical Evaluation • History Timeof meconium passage after birth(within 48 hours) – delayed in preterm. Age of onset of constipation Stool frequency and consistency Size of the stools Pain during defecation or retentive posturing. Blood in stools or toilet paper. Presence of abdominal pain or distension
- 18. Loss of appetite Fever Nausea Vomiting Weightloss or weight gain Problems with neuromuscular development Behavioural or psychological problems Presence of urinary incontinence or urinary tract infections Dietary history Previous treatment history School problems or sexual abuse
- 19. • Examination Measurement ofweight and height – obesity – predisposting factor for constipation Short stature – metabolic disorders Abdominal examination – accumulation of gas or feces, left iliac fossa tenderness Perianal region – position of anus, fecal incontinence, anal fissures, hemorrhoids, eczema, signs of sexual abuse Anorectal digital examination – sphincter tone, perianal sensation, palpable fecal mass, size of rectum Lumbosacral area inspection – spina bifida
- 20. Laboratory investigations • ESPGHANand NASPGHAN recommended that routine laboratory tests to screen for organic cause in constipation is not required in the absence of alarm symptoms. • Because of the fact that only minority of children with constipation are diagnosed with a new organic disease in routine investigations.
- 21. Radiologic investigations • Abdominalradiography • Colonic transit time studies • Abdominal USG • Contrast enema • Anorectal manometry • Colonic manometry • MRI of spine
- 22. Treatment ESPGHAN/NASPGHAN guidelines includesfour phases in treatment 1. Education 2. Disimpaction 3. Prevention of reaccumulation of feces 4. Follow-up.
- 23. Education • Explanation toparents and children. • Explanation about the vicious circle of constipation – fecal retention – fecal incontinence • Clarification regarding fecal incontinence. • No quick solution • Recovery is slow but possible • Can relapse in future
- 24. Disimpaction • Disimpaction orremoval of fecal impaction is recommened prior to maintenance therapy • Oral laxatives – less invasive & cost effective • PEG most commonly used – dose is 1.0-1.5 gm/kg/day • Fecal incontinece episodes increase initially after treatment, decreased significantly later after succesful disimpaction. • Rectal enemas – used for many years in past for fecal impaction – fast onset of action, more invasive • Manual disimpaction – rarely done – only under anaesthesia
- 25. Prevention • Can beachieved through combination of dietary changes, behavioural interventions and medications
- 26. • Dietary changes– common recommendation is to increase the amount of their child’s daily fluid intake. Limited evidence that additional fiber intake improves constipation. Well balanced diet is the most reasonable suggestion to parents and children. • Probiotics supplementation has not shown to improve constipation symptoms.
- 27. • Behavioural interventions– toilet training (sit on the toilet for upto 5 mins, three times a day, following meals to take advantage of gastrocolic reflex) • Daily diary to record bowel movements helps in monitoring progress and compliance. • Coexistence behavioural problems often is associated with poor treatment outcome
- 28. Maintainence- Medication • Oraldaily laxative therapy should be started immediately after disimpaction. • Osmotic laxatives – soften the stools by retaining water within colon through osmosis.PEG based laxatives commonly used worldwide. • Serotonin agonists – cisapride, tegaserod – withdrawn. Prucalopride (selective, high affinity 5HT4 receptor agonist) has shown to improve the symptoms in children in one study. • Lubiprostone – chloride channel activator, improves bowel habits in adults. No studies in children.
- 30. • Enemas –retrograde/antegrade • Surgery – before surgery, organic cause must be ruled out. • Rectosigmoid resection – severe constipation – development of megarectum, megasigmoid or both – resection improves stool pattern and quality of life. • Anal dilation – no benefit in children in long term follow up studies. • Intrasphincteric injection of botulinum toxin – diagnostic and treatment. • Sacral nerve modulation – new treatment for patients with intractable functional constipation. Clinical studies limited to adults. Lack of evidence in pediatric group.
- 32. Treatment of FI •Responds poorly to laxatives. • Behavioural therapy of toilet training + reward system is the most important step in the management of FNRFI. • Surgical intervention has no use in management.
- 34. QUESTIONS • The diagnosisof constipation is based on a) Thorough medical history taking and physical examination b) A+abdominal Xray c) A+ laboratory testing d) A+B+ laboratory testing
- 35. • Treatment ofconstipation consists of a) Education b) Disimpaction c) Maintenance therapy d) Follow up e) All of the above