Transcript Good Morning! - LSU School of Medicine

Good Morning!
Tuesday, April 3rd 2012
Nonorganic
Functional fecal retention
Anatomic
Anal stenosis
Imperforate anus
Anteriorly displaced anus
Intestinal stricture (post NEC)
Abnormal musculature
Intestinal Nerve/Muscle
Abnormalities
Hirschsprung disease
Pseudo-obstruction
Intestinal neuronal dysplasia
Spinal Cord Defects
Tethered Cord
Spinal cord trauma
Spina bifida
Prune-belly
Gastroschisis
Down syndrome
Causes of Constipation
Drugs
Intestinal Disorders
Anticholinergics
Celiac disease
Narcotics
Antidepressents
Cow’s milk protein intolerance
Chemotherapy
Cystic fibrosis
Pancreatic enzymes
Inflammatory bowel disease
Lead
Tumor
Vitamin D intoxication
Metabolic Disorders
Hypokalemia
Hypercalcemia
Connective Tissue
Disorders
SLE
Scleroderma
Hypothyroidism
Psychiatric Disorders
Diabetes Mellitus
Anorexia nervosa
Causes of Constipation
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5% of all outpatient pediatric visits
25% of referrals to pediatric GI
Definition:
◦ Infrequent bowel evacuation
◦ Hard small feces
◦ Difficult or painful evacuation of large-diamter
stools
◦ Fecal incontinence (encopresis)
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Its all relative
◦ A child with 3 small stools a day may not have
evacuated colon, but a child with 2 large soft
stools a week is not constipated
Constipation
90% of newborns pass meconium in 1st
24 hours
 Intestinal transit time
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◦ 8 hours = 1 month
◦ 16 hours = 2 years
◦ 26 hours = 10 years
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Infant dyschezia
◦ 10 minutes of straining and crying before
successful passage of soft stool in otherwise
healthy infant; failure of pelvic floor to relax;
resolves spontaneously
Normal Stooling Patterns
Repetitive denial of evacuation due to pain
leads to stretching of rectum and lower
colon
 Reduction in muscle tone
 Retention of stool
 Longer the stool remains in rectum, more
water is removed, harder the stool
becomes to point of impaction
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Vicious cycle of constipation
Accounts for 95% of cases
 Persistent, difficult, infrequent, or
incomplete defecation without evidence of
anatomic or biochemical cause
 Peaks in pre-school years
 3 periods prone to constipation:
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◦ Introduction of cereals and solid foods
◦ Toilet training
◦ Start of school
Functional Constipation
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Toddlers and older children may withhold
stool:
◦ Painful defecation
◦ Avoid defecation in a strange toilet away from
home
◦ Too distracted (ADHD)
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Symptoms:
◦ Early satiety, desire to eat small volumes all
day, increasing irritability, spasms of abdominal
pain in lower abdomen
Functional Constipation (cont’d)
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A 5-year-old girl has a confirmed urinary tract
infection. She has had 4 UTIs in the past 2 years,
which all resolved with antibiotics. She denies
urgency and frequency. The only significant
history is constipation. Renal U/S and VCUG are
normal. Her growth is normal. You prescribe
Bactrim.
Of the following, the MOST appropriate additional
step to reduce future UTIs is:
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A. Begin evaluation for immunodeficiency
B. Perform renal scintigraphy
C. Prescribe stool softener and regular bowel routine
D. Prescribe oral oxybutynin
E. Refer to pediatric nephrologist
Question
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Passage of meconium
Transitions: breastmilk to formula to cow’s
milk; child care to all-day school; diapers
to toilet training
Family history
Character of stools
Encopresis
Past medical history
Medications
*Urinary incontinence
History
Growth and weight gain
 Umbilical girth
 Abdominal exam
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◦ Bowel sounds
◦ Palpable dilated loops
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Rectal exam
◦ Distended rectum full of stool
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Back (look for sacral skin findings)
Physical Exam
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Plain abdominal radiograph
Thyroid function, electrolyte levels,
magnesium
*UA, urine culture
Lumbosacral spine films/MRI
Barium enema
Lead level
Motility testing
◦ Colon transit studies
◦ Anorectal manometry
◦ Consider in pts. with no organic cause of
constipation, but failure to respond to aggressive
treatment
Laboratory
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Lack of ganglion cells in the myenteric and
submucosal plexus of bowel wall
Onset of symptoms in 1st week of life
Delayed passage of meconium (after 48
hours)
Abdominal distention
Vomiting
Transition zone on enema
Failure to thrive
Acute enterocolitis
60% diagnosed by 3 months of age
Absence of encopresis
*Hirschsrung Disease
Hirschsprung Disease
Repeated involuntary fecal soiling in the
underpants
 Children should obtain fecal continence by
the age of 4
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◦ *Encopresis is a symptom rather than a
developmental variation after age 4 to 5
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90% is functional
◦ Retentive constipation with overflow
incontinence
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*5 to 10% is organic, behavioral,
environmental (privacy issues)
◦ Anatomic, neurologic, metabolic, iatrogenic
Encopresis
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Phase 1: Disimpaction
Management of Chronic
Constipation and Encopresis
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Phase 2: Maintenance
◦ Pattern of daily defecation should be
maintained
◦ The goal is to maintain soft bowel movements
once or twice a day
◦ This phase can last from 2 to 6 months or
longer
 Months are required for rectum to return to
normal caliber and regain normal sensation
◦ *Best approach is a combination of medical
therapy, behavioral modification, and
counseling
Management of Chronic
Constipation and Encopresis
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Behavior
modification
◦ Patient should sit on
toilet for 10 minutes
after meals 2-3
times/day
◦ A footstool may be
used to help improve
the Valsalva
maneuver
◦ “Star” charts
Management of Chronic
Constipation and Encopresis
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Anorectal dyssynergia
◦ Paradoxic increase in external sphincter tone
while trying to defecate
◦ Diagnosed with anorectal manometry
◦ Patients are candidates for biofeedback therapy
with manometry
Behavior Modification
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Phase 3: Weaning From Medication
◦ Start when child consistently is achieving 1 to
2 soft bowel movements daily
◦ Usually after 6 months
◦ Wean stimulant laxatives first, then lubricant or
osmotic agents
Management of Chronic
Constipation and Encopresis
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Diet
◦ High-fiber diet
 Shown to increase number of bowel movements
and decrease episodes of encopresis
 Avoid until child is no longer withholding stool,
because bulking with fiber may lead to additional
withholding
 Whole grains, fruits, and vegetables
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Probiotics
◦ Have been shown to improve colonic transit
time
◦ More studies are needed
Management of Chronic
Constipation and Encopresis
Patients who show no improvement after
6 months should be referred to GI
 *Relapses are common!
 Rates of recurrence approach 50%
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Relapse