Approach to a child with Constipation
- 1. APPROACH TO A CHILD WITH CONSTIPATION DR RAVIKUMAR PEDIATRIC RESIDENT MGMCRI
- 2. Table Of Contents Prevalence Definition Risk Factors Etiology Pathogenesis Of Functional Constipation Clinical Manifestation Hirshsprung Disease Approach Management Refractory Constipation Approach to Constipation 2
- 3. Prevalence Constipation is a global health problem Worldwide prevalence of functional constipation is 3% It is commonly seen among toddlers and preschool children In a study from India, reported 138 cases of constipation diagnosed over a period of six years and 85% of them were functional Approach to Constipation 3
- 4. Definition ROME III Criteria Functional constipation is defined as presence of two or more of the following in absence of any organic pathology and the duration should be atleast one month in <4 years of age, and at least once per week for at least 2 months in ≥4 years of age : (i) Two or less defecations per week, (ii) Atleast one episode of fecal incontinence per week, (iii) History of retentive posture or stool withholding maneuver, (iv) History of painful or hard bowel movement, (v) Presence of large fecal mass in the rectum, (vi) History of large-diameter stools that may obstruct the toilet. Approach to Constipation 4
- 5. Definition Encopresis is the regular, voluntary or involuntary passage of feces into a place other than the toilet after 4 years of age Obstipation refers to the absence of passage of both feces and flatus and denote often an underlying organic obstruction or pseudo- obstruction Approach to Constipation 5
- 6. Category Risk factors Patient Related Male sex Poor Sleep Obesity Dietary Low fiber Consumption of junk food Cow’s milk protein allergy Psychological Home/School-related stresses Adverse life event including abuse Subjected to bullying Anxiety Depression Autistic spectrum disorders Social Living in war-affected areas Living in urban areas Lower social class Hostile and aggressive family environment Approach to Constipation 6
- 7. Etiology Functional constipation of childhood: Poor dietary habits including weaning formula & lack of fiber. Motility related: Hirschsprung disease, myopathy Congenital anomalies: Anal stenosis, anteriorly located anus, spinal cord anomalies (meningomyelocele, myelomalacia, spina bifida) Neurological: Cerebral palsy, mental retardation Endocrine/metabolic: Hypothyroidism, renal tubular acidosis, diabetes insipidus & hypercalcemia Drugs: Anticonvulsants, antipsychotic, codeine containing cough syrup & anti-diarrheal. Approach to Constipation 7
- 8. Pathogenesis Of Functional Constipation Approach to Constipation 8
- 9. Vicious Cycle of Events Fecal Retention Rectal distension Decreased sensory perception Hard stools Pain during defecation Partial evacuation Impaction Fecaloma formation Approach to Constipation 9
- 10. Clinical Manifestation Children adopt peculiar postures during defecation with many crossing their legs or attempting to defecate in the standing position. Abdomen Examination Palpable Fecolith in the left lower abdomen Digital Rectal Examination Rectum is usually loaded with hard stools Approach to Constipation 10
- 11. Approach to Constipation 11
- 12. Red Flags Fever Vomiting Bloody diarrhea Failure to thrive Anal stenosis Tight empty rectum Approach to Constipation 12
- 13. Careful Clinical History to Rule out Organic Cause: Apart from Constipation, Recurrent abdominal pain Poor feeding Enuresis Voiding disturbances Urinary infections Most Important history to distinguish Hirschsprung disease from functional constipation - delayed passage of meconium beyond 48 hours & onset in first month of life. Approach to Constipation 13
- 14. Abnormal Physical Findings to rule out Organic Cause: Failure to thrive Tuft of hair over spine/ spinal dimple Lack of lumbo-sacral curve Sacral agenesis Flat buttock Anteriorly displaced anus Tight and empty rectum Gush of liquid stool and air on withdrawal of finger Absent anal wink and cremasteric reflex. Approach to Constipation 14
- 15. Functional vs Hirschsprung Disease Features Functional Hirschsprung Delayed Passage of Meconium None Common Onset After 2 years At birth Fecal Incontinence Common Very rare History of Fissure Common Rare Failure to thrive Uncommon Possible Enterocolitis None Possible Abdominal Distension Rare Common Rectal Examination Stool Empty Malnutrition None Possible Approach to Constipation 15
- 16. X-Ray of Functional Constipation Approach to Constipation 16 (Delayed Film)
- 17. Diagnosis of Hirschsprung Barium enema – Not necessarily indicated in all cases Can be done only if there is strong clinical suspicion (based on the history of delayed passage of meconium & empty rectum) Interpretation - should be on the basis of reversal of recto sigmoid ratio (sigmoid becomes more dilated than rectum) and documentation of transition zone and not on mere presence of barium in rectum after 24 Approach to Constipation 17
- 18. Approach to Constipation Approach to Constipation Modified from ESPGHAN Recommendations 18
- 19. Management Steps: 1. To determine presence of fecal impaction 2. To treat the impaction if present 3. Initiate Maintenance treatment with oral laxative, dietary modification & toilet training 4. Close follow up and medication adjustment as necessary. Approach to Constipation 19
- 20. Disimpaction PEG Oral: 1-1.5g/kg/day for 3-6 days NG tube: 25ml/kg/hr until clear fluid is excreted through anus Successful disimpaction for Homebased regimen is defined as either empty or a small amount of soft stool on DRE and resolution of fecolith Adequate disimpaction means both lavage (input) and stool (output) should be of same color in case of NG tube disimpaction Approach to Constipation 20
- 21. Disimpaction If PEG is not available, then enema can be used Proctoclysis by Sodium phosphate: 2.5 mL/kg, maximum 133ml/dose for 3-6 days Mineral oil is also equally effective for disimpaction with dose of 15-30 mL/yr of age (max. 240mL) For infants : Glycerine suppositories are to be used for disimpaction as enemas and lavage solution are not indicated Approach to Constipation 21
- 22. Maintenance Therapy 1) Dietary Modification • Encouraged to take more fluids, absorbable and non absorbable carbohydrate (sorbitol) as a method to soften the stools • Sorbitol is found in fruit juices like apple, pear and prune • A balanced diet that includes whole grains, fruits and vegetables is advised • The recommended daily fiber intake is Age(in years) + 5 in g/day Approach to Constipation 22
- 23. Maintenance Therapy 2) Toilet Training Implemented after 2 to 3 years of age Encouraged to sit on the toilet for 5 to 10 minutes, 3 to 4 times/day immediately after major meals initially Advised to maintain “Stool Diary”- daily record of bowel movements, fecal soiling, pain/discomfort, consistency of stool and the laxative dose Positive Reinforcement - should be rewarded for not soiling and for regular sitting on the toilet Approach to Constipation 23
- 24. Maintenance Therapy 3) Laxatives: Approach to Constipation 24 Drugs Dose Adverse effects Lactulose 1-2 g/kg, 1-2 doses Bloating, abdominal cramps PEG for maintenance 5-10 mL/kg/d or 0.4 to 0.8 g/kg/d Nausea, bloating, cramps, vomiting Mineral oil for maintenance 1-3 mL/kg/d Lipoid pneumonia, interference with absorption of fat soluble vitamins Milk of Magnesia 1-3 mL/kg/d, 1-2 doses Excess use leads to hypocalcemia, hypermagnesemia, hypophosphatemia Bisacodyl 0.3 mg/kg/dose 5mg-10mg suppository Abdominal pain, diarrhea, hypokalemia
- 25. Follow-up Schedule Monthly follow up till regular bowel movement is achieved: Check diary, physical and rectal examination. Laxative dose is to be adjusted Follow-up of 3 months for next 2 years: Continue same dose of laxative for at least 3 months and then slow tapering Yearly follow-up: Points to be remembered while treating infants with constipation are to exclude organic causes such as HD, cystic fibrosis, cretinism, etc. to avoid mineral oil, stimulant laxatives and glycerine enemas for fecal impaction. Approach to Constipation 25
- 26. Refractory Constipation Refractory is labelled when there is no response to optimal conventional treatment for at least 3 months Causes: Motility disorders (like slow transit constipation) Disorders of stool expulsion like dyssynergic defecation Internal anal sphincter achalasia Sphincter dysfunction in children with Hirschsprung disease which persist after surgery Motility studies like colon transit time (CTT), anorectal manometry with balloon expulsion test, colonic manometry Approach to Constipation 26
- 27. CTT study Simplest and most informative of all the tests Done by use of radio-opaque markers and by radionuclide scintigraphy Classified: (i) Normal transit constipation (ii) Functional outlet obstruction or dyssynergic defecation () (iii) Slow transit constipation (retained markers are distributed all over) Approach to Constipation 27
- 28. Slow Transit Constipation CTT by radio- opaque markers showing Reduced motility of large intestine caused by abnormality of enteric nerves Approach to Constipation 28
- 29. Functional outlet Obstruction CTT study showing retention of markers in rectosigmoid region Approach to Constipation 29
- 30. TAKE HOME MESSAGE Detailed history and proper physical examination, including digital rectal examination, can easily differentiate functional from organic constipation Nearly 95% is of it is functional and often does not need any investigation In most cases, prolonged (months to years) laxative therapy is required and early withdrawal leads to recurrence Approach to Constipation 30
- 31. REFERENCES 1. Nelson Textbook of Pediatrics 2. Indian Pediatrics “Approach to Constipation in Children” 2016 article 3. IAP Textbook of Pediatrics Approach to Constipation 31