Transcript CONSTIPATION

CONSTIPATION
Dr. Soad Jaber
2009
Constipation
Physiology of defecation
 Understand the differences between

 Constipation
 Encorporesis
 Soiling
Identify major causes of constipation
 Differences between functional and
organic causes
 Understand the principle behind
constipation management

CONSTIPATION
Physiology of defecation

In normal subjects : Distention of the rectum
Reflex relaxation of internal sphincter
Contraction of external sphincter
*Lower rectum is normally empty
*Entry of fecal material from above gives the sensation of the
need to defecate.

If the rectum is chronically distended the sensation is lost 
retention of stool  full rectum
Constipation:

 Delay
or difficulty in defecation that
has been present for two weeks or
longer. is associated with anal and
abdominal discomfort.
 Full rectum
Functional Constipation:
Is a voluntary withholding of stools
Starts after the neonatal period
Usually develop after passage of
painful bowel movement.
Encopresis:
 Day
or night time passage of formed
stool into inappropriate places
beyond the age expected for toilet
training (4-5 year
 Abnormal anal sphincter physiology.
Types of Encopresis:
A)RETENTIVE encopresis with constipation
and overflow incontinence.2/3
B)Non RETINTIVE encopresis: without
constipation and overflow.1/3
(A
(A
OR :1ry from infancy occur with global (B
developmental delay and enuresis.
2ry:after successful toilet training occur with (C
psychosocial stress and mismanagement
Soiling:
Involuntary escape of fluid or semi
fluid stools into the under clothing
usually due to overflow from a
loaded cecum with feces which leads
to stretch of internal sphincter
Neurogenic Soiling:
Soiling which occur due to neurological
abnormalities:
Spinal bifida
Paraplegia
Myelomengiocel
Causes of Constipation:
A.
Infants and Children:
1. Non-organic Causes
.Lack of dietary fibers
.Inadequate fluid intake
.Failure to develop regular bowel habits
(neglect, stubborn child, MR)
.Follow illness
.Change in environment or routine
(Holidays… school entry)
Organic cause
Anatomic(anaal 
stenosis,imperforatecanus,anteriorly
displaced anus.intestinal stricture)
Abnormal musculature(prune-belly 
syndrome,Gastroschisis,Down syndrome
Intestinal nerve or muscle 
abnormalities(Hirschprung diease)
Spinal cord defects(spinal cord trauma or
spina bifida)
Drugs(Anticholinergics or 
narcotics<Vincristine,vit D
intoxication,Lead)

Metabolic 
disorders(Hypokalemia,hypercalcemia,hyp
otghyroidism,D.M)
Intestinal disorders:(celiac disease,cow 
milk protein intolerance,meconium
ileus,inflammatory bowel disease,tumour)
Connective tissue 
disordersSLE,sclerderma)
Psychiatric diagnosis(Anorexia nervosa) 
2. Organic Causes
•
Hirschsprung’s disease
*Clinical clues

Delayed muconium passage > 48h or early
onset of constipation

Empty rectum on examination Normal anal
tone

Absence of ganglia in rectal sub mucosal
biopsy

Barium enema  transition zone

Manometery --- absence of internal
sphincter relaxation
Conflict in training
defecate
Stool retention

Pain in defecation

withholding the stools

 distention of the rectum

 Rectal sensation

necessitating a greater fecal
mass to initiate the urge to
Complication of stool retention
Impaction
 Abdominal pain
 Overflow diarrhea  leakage around the
fecal mass
 Anal fissure
 Rectal bleeding
 Urinary tract infection

Management:
 History
and clinical examination
should reduce the number of
investigation
e.g. anal fissure
 History of change in environment or
diet
 Presence of hard impacted stools
 Barium study:?XRAY
.large rectum or recto -segmoid
.impaction of stool
B. Elder Children
He might present with recurrent
abdominal pain
 He might develop soiling
 The elder child will eventually reach the
stage where he is very quiet, withdrawn
and isolated from his classmates
 Parents and child should participate in a
group discussion and plan the
management to help the child

*If with soiling advise of Psychiatrist
1.
2.
3.
4.
5.
Medical
Hypertonic phosphate enemas daily
or every other day for 1 week.
Mineral oil 30-60 mls twice daily
between meals to minimize its effect
in impairing the absorption of fat
soluble vitamins --  with the
response to stop within the period of
about 6 months.
Ensure that the child has sufficient
fluid and fiber in the diet
Bulk type of softness (Metamucil)
maybe administered as the dose of
mineral oil is tapered.
Lactulose, senna, may have to be
prescribed to break the vicious cycle
of fecal retention and pain
Dietary Measures
 Intake of fluid
High residual diet, bran – whole
wheat
Fruit and vegetable
Prune Juice
Anal Dilatation
 Old method – local anesthesia
 Well lubricated little finger inserted
into the anus and kept for 1 minute
INFANTS
*Treat the cause
 Simple constipation … correct diet
… add
fiber… treat anal fissure .. Softening the
stool to break the cycle
 Daily stitz bath
 Application of Vaseline ointment after the
bath
 Anesthetic ointment.
Managements:
Hx
Onset
Associated findings
FTT  organic
Ex
Abdominal
Rectal
Signs of Hypothyroidism
Explanation
Common problem
Will get better
Physiology of defecation
Long term managements up to 1 year
Goals:
1.
Empty Rectum
Clean out retained stool
Enema
Suppositories
Senakot
Bowel cleaning
2. Bulky stool
High fiber diet (bran)
3. Improve habits
Regular time of toilet after feed
Stars chart
Position- squatting
De emotionalize home
environment
Functional Constipation:
WHY MAY THE TREATMENT FAIL ?!
 Inadequate
clean out 
suppositories
 Inadequate dosage of medication
 On and off approach:
Intermittent use of medication
Malabsorption
Objectives:
 Digestion
 Definition
 Identify
major causes of
malabsorption
 Know to work up for malabsorption
Malabsorption
Digestion

Stomach -------

Small bowel----
breakdown ingested food
by rhythmic contraction
gastric acids.
Intestinal secretion 
digestion.
*Brush Border
Small bowel 2 halves
Jejunum
CHO
maltose
Fat
F.A. mono glycerides
Protien..di ,tri, tetra peptides + a.a.
Minerals
Vitamins
Water
Ileum
Water
B12
Bile salts
Malabsorption Syndromes
Malabsorptive disorders
They are conditions that cause insufficient assimilation of ingested
nutrients either as a result of mal digestion, or malabsorption.
General presentation:
Abdominal distention
Pallor
Foul smelling stools
Bulky stools.. Normal… greasy…steatorrhea
muscle wasting
Poor weight gain … weight loss
Growth retardation
Clues:
Acute diarrhea --- infection
chronic diarrhea > 3 weeks
? Malabsorption
Blood,FTT
Overall appearance of the child
I. Malabsorption according to age
of presentation
1. From birth up to two years of age:
–
–
–
–
–
–
–
–
–
–
Post infectious
Protein intolerance
Congenital microvillus inclusion disease.
Glucose – galactose transport defects.
Congenital chloride diarrhea
Familial chronic villous atrophy
Immune deficiency disease
Cholestatic liver disease
Gluten sensitive enteropathy
Anatomical cause (short bowel syndrome)
2. Older children:
–
–
–
–
Cystic fibrosis
Crohn’s disease
Gluten sensitive enteropathy
Acquired lactose deficiency
II. Malabsorption according to
substances:
1. Fat
Celiac disease
Cystic fibrosis
OTHERS:
Giardiasis
Congenital intestinal malformation
Crohn’s disease
Biliary atrasia
Liver cirrhosis
2.Carbohydrate
Glucose -galactose transport
defect
Genetic Lactose (Primary lactase deficiency)
Sucrose (Congenital sucrase –
isomaltase deficiency)
Secondary
celiac disease
any chronic diarrhea
3. Protein
Follow any chronic diarrhea
Enzyme deficiency (trypsinogen)
Allergy… Cow’s milk protein
4. Vitamins
Fat soluble Vit. Secondary to
steatorhea
B12 … Crohn’s
III. Malabsorption according to site
of defects.
1.
Mucosal
Small intestinal injuries resulting in secondary
deficiencies.
- Celiac disease
-
Bacterial over growth
Cow’s milk enteropathy
Giardiasis
Rota virus infection
Chronic protracted diarrhea
Protein energy malnutrition
Crohn’s disease of small intestine
Short bowel syndrome
Drugs …neomycin … colchicines
Radiation enteritis
2. None mucosal
Pancreatic disease
Bile losses
------ cystic fibrosis
---- bacterial overgrowth

deconjugation of bile acids

Cholestasis
Lymphatic obstruction-----lymphagiactasia
A Beta–lipo proteinemia
How to approach:
History:





Is he/she thriving
Weight/height
Appetite
Other symptoms --- edema
Repetition of symptoms with reintroduction of certain foods
e.g.
Gluten
Lactose
Cow’s milk

Stool
Greasy
Oil slik in the toilet
Frothy – sugar intolerance
Smell --- Rancid, CF
-----foul, celiac
Examination
Growth chart
Pallor
--- Iron, folate
Clubbing
CF, IBD, CD
Chest problem CF
Distended abdomen CD
Muscle hypotonia + wasting
Nappy rash
Rectal examination (prolapsed)
Laboratory investigations:
1.
Stool
1.microscopic examination
– Fat droplet (stool + water + Sudan red stain)
– 72 hours stool collection
– Stool Giardia Cyst
ELISA for Giardia antibodies.
2. Stool PH  5.6 (CHO)
3. Spot  antitrypsin level ( 2 days stool)
4. Stool reducing substance
– Chromatography
– Clintest tab
10 drops water + 5 drops stool+tab
(-ve -- 4+) Color coding 2 + or 
suggest CHO malabsorption
Sucrose is not reducing substance
Should be hydrolyzed by HCl before analysis
5. Stool osmolarity (stool electrolyte content)
290 - 2(Na + K ) meq/L


 100 mosm/L  secretary as in cong chloride
diarrhea
 100 mosm/L  Osmotic diarrhea  CHO
intolerance
2. Blood





CBC—
blood film-------
A canthocyte
hypochromic, microcytic anemia
macrocytosis
Serum albumin
Serum immunoglobulins
Trypsinogen (screening)
Nutrients in blood
Iron .. Transferrin concentration
folic acid –---- RBCs concentration ,not serum
Ca, Mg, Vit D., Vit A
B12 -- bile salt
Vit E + Serum lipids
Vit K ( PT , PTT)
3. Others
 Sweat
chloride test
 Hydrogen breath test
 D-xylose test
 Schilling test (Vit B12)
4. Diagnostic Procedure:
1.
Small bowel biopsy:
1. Duodenal mucosa
Giardia trophozoite
Colony count of bacteria
Culture of proximal juice
2. For HIV
parasitic bacteria or virus
viral opportunistic entral pathogen
3. Gluten sensitive enteropathy
Challenge test
4. Congenital microvillous inclusion disease
5. Eosinophillic gastroenteritis
6. Infectious disorders
2. Imaging procedure
X-ray – site of colon - e.g. intestinal mal rotation
Ultra sound (biliary tree.. Pancreas)
Barium contrast meal and follow through
Barium enema
Review of some disorders
I. Disorders of CHO intolerance
Symptoms
Flatulence, Diarrhea, bloating, vomiting, abdominal
cramping, barborygmi
A. Congenital Disorders
Lactose deficiency
cong (rare)
TX Lactose hydrolyzed milk.
Lactid tab


Acquired
Sucrase deficiency:
Recurrent watery diarrhea,

stool PH below 6
Glucose – Galactose malabsorption.
Very rare
neonates
acidosis
TX fructose formula
severe hypoglycemia –
B. Acquired disorders:
Secondary to acute viral OR bacterial
gastro enteritis…. lactase def > sucrase
 Generally children tolerate lactose
withen (3w-3m)
Stool PH 6
+ve clinitest tab
 Secondary to celiac disease, Crohn’s
disease, ulcerative colitis
TX – lactose free diet

II. Disorders of Proteins

Cow’s milk protein sensitivity
A topic individuals
Jejunal atrophy
Colonic bleeding
Iron deficiency anemia unresponsive to
treatment with oral iron.
TX D/C milk
Repeat challenge with carefully increasing
dose majority will tolerate milk by two years.
40% intolerant to Soya protein.
 Celiac
disease
Allergy
to Gliaden portion of gluten
(wheat, Rye, Oats or barley)
– Screening antibodies
Antigliadin IgA, Anti reticulin, Anti
endomyseal EMA
Celiac Sprue: Gluten sensitive enteropathy
C/P
Abdominal distention
Weight loss –FTT
irritability
Vomiting
Steotorrhea
mild cases,
IDA,,, short stature ,,,delayed puberty
Investigation: Serum Iron
 folic acid
 albumin
Flat Glucose tolerance test
EMA +ve,, ,+ve
Antigliadin
Small bowel biopsy
100% diagnostic
- villous atrophy on a gluten free diet
- Recurrence after a gluten challenge
Treatment: Gluten free diet for life
Prognosis: Strict diet - Normal growth – health
- 1% lymphoma
Causes of flat small intestinal
mucosa:
1.
2.
3.
4.
5.
6.
7.
8.
Celiac disease
Cow’s milk protein sensitivity
Post enteritis syndrome
Giardiasis
Tropical sprue
Soya protein intolerance
Autoimmune enteropathy
Protein energy malnutrition
Mucoviscidosis
Cystic fibrosis


AR
Defect:
Mucus secreted by exocrine glands is
abnormally thick and sticky due to defect in
chloride permeability which lead to failure in
maintaining the luminal hydration.
It is an obstructive lesion in which a duct or
airway passage is blocked by intra luminal
mucous and other protein.
60% presents before 1 year. 85% before 5
years
C.P. Most presented with failure to thrive
frequent foul smelling stocl
Rectal prolapse 18.5% by 1-2 Yr.
10% muconium illeus
- a plug of muconium in the terminal ileum
which lead to ischemic
ulceration and
peritonitis
- delayed passage of muconium in neonate
10% Pancreatic fibrosis
Exocrine insufficiency 
malabsorption
80%
Recurrent chest infection
Atelactasis
 Bronchiactasis 
Emphysema 
Corpulmonal 
death
Rare
Boys
Azospermia
infertility
Liver  obstructive jaundice
biliary cirrhosis
Gallbladder  Gall stones

Investigation:
1.
24 hour stool chymotripsin
2.
True test for pancreatic function : by low
enzyme output from Pancreas, follow
stimulation by secretin and cholecytokinin
3.
Sweat test. (Sweat chloride measurement)
 60 meq/L -------- diagnostic
If doubtful as is cases of edema , sweat
test should be repeated once edema subside
Treatment:
Enteric coated – acid resistant oral pancreatic
enzyme supplements
Diet high in protein, low fat or MCT diet
CYSTIC FIBROSIS
A.R.
Exocrine gland abnormalities

Electrolyte transport defect + inspissated mucous
Sweat
Salivary
Glands
gland
deference
Pancreatic
duct
Pancreas
Lung
Liver
vas
Bronchial
Obstruction
Obstruction
Defective Na + cl
male
Absorption
infertility
By gland
and infection
Defective HCO3
Pancreatic fibrosis
Secretion
Biliary duct
Obstruction
Chronic
Obstructive
lung disease
Biliary cirrhosis
Pancreatic
insufficiency
Cor pulmonale
mal absorption
muconium
ilieus
Inflammatory bowel disease
A. Croh’s disease: Regional enteritis
Transmural inflammation with skip areas
Genetic predisposition
Post prandial abdominal pain . ± diarrhea or constipation
weight loss
fever
arthralgia /arthritis
2% Erythema nodosum
Investigations:
 ESR
Anemia
 albumin
:
Proctoscopy
Double contrast colon X-ray
Rectal biopsy
C/P
Treatment:
 iron
Enteral or parentral nutrition
Medicine - Prednisone
- Sulfasalazine (if colonic involvement)
- Azathoprine
- Cyclophosphamide
-70% surgical treatment
B. Ulcerative colitis


Mucosal inflammation ---rarely involve muscularis layer
Toxic mega colon
C/P
bloody diarrhea + tenesmus
Complication Hge
Mega colon
intractable symptoms
Arthalgia
/ arthritis
high risk of colonic cancer
Treatment:
Enteral and parentral nutrition
medical: - Sulfasalazine oral
- hydro cortison enema
- systemic predisone
- Cyclo sporins
25% surgical treatment colectomy if mega colon
Thank You