Transcript FAILURE TO THRIVE

Constipation
BY
DR.RANDA AL-GHANEM
PEDIATRIC GI CONSULTANT
 DEFINITION
 INFREQUENT BOWEL MOVEMENTS (TYPICALLY THREE TIMES OR
FEWER PER WEEK)
 DIFFICULTY DURING DEFECATION (STRAINING DURING MORE
THAN 25% OF BOWEL MOVEMENTS OR A SUBJECTIVE SENSATION
OF HARD STOOLS), OR
 THE SENSATION OF INCOMPLETE BOWEL EVACUATION.
 CONSTIPATION IN CHILDREN USUALLY OCCURS AT THREE
DISTINCT POINTS IN TIME: AFTER STARTING FORMULA OR
PROCESSED FOODS (WHILE AN INFANT), DURINGTOILET
TRAINING IN TODDLERHOOD, AND SOON AFTER STARTING
SCHOOL.
 AFTER BIRTH, MOST INFANTS PASS 4-5 SOFT LIQUID BOWEL
MOVEMENTS (BM) A DAY.
 BREAST-FED INFANTS USUALLY TEND TO HAVE MORE BM
COMPARED TO FORMULA-FED INFANTS.
 SOME BREAST-FED INFANTS HAVE A BM AFTER EACH FEED,
WHEREAS OTHERS HAVE ONLY ONE BM EVERY 2–3 DAYS.
 INFANTS WHO ARE BREAST-FED RARELY DEVELOP
CONSTIPATION.
 BY THE AGE OF TWO YEARS, A CHILD WILL USUALLY HAVE 1–2
BOWEL MOVEMENTS PER DAY AND BY FOUR YEARS OF AGE, A
CHILD WILL HAVE ONE BOWEL MOVEMENT PER DAY.
 CAUSES
 THE CAUSES OF CONSTIPATION CAN BE DIVIDED
INTO CONGENITAL, PRIMARY, AND SECONDARY.
 THE MOST COMMON CAUSE IS PRIMARY AND NOT LIFE-
THREATENING.
 IN THE ELDERLY, CAUSES INCLUDE: INSUFFICIENT DIETARY FIBER
INTAKE, INADEQUATE FLUID INTAKE, DECREASED PHYSICAL
ACTIVITY, SIDE EFFECTS OF MEDICATIONS, HYPOTHYROIDISM,
AND OBSTRUCTION BY COLORECTAL CANCER.
 FEMALES ARE MORE OFTEN AFFECTED THAN MALES.
 PRIMARY
 PRIMARY OR FUNCTIONAL CONSTIPATION IS ONGOING
SYMPTOMS FOR GREATER THAN SIX MONTHS NOT DUE TO ANY
UNDERLYING CAUSE SUCH AS MEDICATION SIDE EFFECTS OR AN
UNDERLYING MEDICAL CONDITION.
 IT IS NOT ASSOCIATED WITH ABDOMINAL PAIN, THUS
DISTINGUISHING IT FROM IRRITABLE BOWEL SYNDROME.
 IT IS THE MOST COMMON CAUSE OF CONSTIPATION.
 DIET
 CONSTIPATION CAN BE CAUSED OR EXACERBATED BY A LOW
FIBER DIET, LOW LIQUID INTAKE, OR DIETING.
 MEDICATION
 MANY MEDICATIONS HAVE CONSTIPATION AS A SIDE EFFECT.
SOME INCLUDE (BUT ARE NOT LIMITED TO); OPIOIDS COMMON
PAIN KILLERS , DIURETICS , ANTIDEPRESSANTS , ANTIHISTAMINES
, ANTI PASMODICS , ANTICONVULSANTS, AND
ALUMINUM ANTACIDS.
 METABOLIC AND MUSCULAR
 METABOLIC AND ENDOCRINE PROBLEMS WHICH MAY LEAD TO
CONSTIPATION INCLUDE:
HYPERCALCEMIA, HYPOTHYROIDISM, DIABETES MELLITUS,CYSTIC
FIBROSIS, AND CELIAC DISEASE.
 CONSTIPATION IS ALSO COMMON IN INDIVIDUALS WITH
MUSCULAR AND MYOTONIC DYSTROPHY.
 STRUCTURAL AND FUNCTIONAL ABNORMALITIES
 CONSTIPATION HAS A NUMBER OF STRUCTURAL (MECHANICAL,
MORPHOLOGICAL, ANATOMICAL) CAUSES, INCLUDING: SPINAL CORD
LESIONS , ANAL FISSURES, AND PROCTITIS.
 CONSTIPATION ALSO HAS FUNCTIONAL (NEUROLOGICAL) CAUSES,
INCLUDING ANISMUS, DESCENDING PERINEUM SYNDROME, AND
HIRSCHSPRUNG'S DISEASE.
 IN INFANTS, HIRSCHSPRUNG'S DISEASE IS THE MOST COMMON
MEDICAL DISORDER ASSOCIATED WITH CONSTIPATION.
 ANISMUS OCCURS IN A SMALL MINORITY OF PERSONS WITH CHRONIC
CONSTIPATION OR OBSTRUCTED DEFECATION.
 PSYCHOLOGICAL
 VOLUNTARY WITHHOLDING OF THE STOOL IS A COMMON CAUSE
OF CONSTIPATION.
 THE CHOICE TO WITHHOLD CAN BE DUE TO FACTORS SUCH AS
FEAR OF PAIN, FEAR OF PUBLIC RESTROOMS, OR LAZINESS.
 WHEN A CHILD HOLDS IN THE STOOL A COMBINATION OF
ENCOURAGEMENT, FLUIDS,FIBER, AND LAXATIVES MAY BE
USEFUL TO OVERCOME THE PROBLEM.
 DIAGNOSIS
- THE DIAGNOSIS IS ESSENTIALLY MADE FROM THE PATIENT'S OR
PARENTS DESCRIPTION OF THE SYMPTOMS ( INCLUDE
BLOATING, DISTENSION, ABDOMINAL PAIN, HEADACHES, A FEELING
OF FATIGUE AND NERVOUS EXHAUSTION, OR A SENSE OF
INCOMPLETE EMPTYING) AND NUTRETIONAL HISTORY.
- DURING PHYSICAL EXAMINATION, SCYBALA (MANUALLY PALPABLE
LUMPS OF STOOL) MAY BE DETECTED ON PALPATION OF THE
ABDOMEN.
 DIAGNOSIS
- RECTAL EXAMINATION GIVES AN IMPRESSION OF THE ANAL
SPHINCTERTONE AND WHETHER THE LOWER RECTUM CONTAINS
ANY FECES OR NOT AND FOR POLYPS.
- A COLONOSCOPE AND X-RAYS OF THE ABDOMEN, GENERALLY ONLY
PERFORMED IF BOWEL OBSTRUCTION IS SUSPECTED.
 CRITERIA
 THE ROME II CRITERIA FOR CONSTIPATION REQUIRE AT LEAST TWO
OF THE FOLLOWING SYMPTOMS FOR 12 WEEKS OR MORE OVER THE
PERIOD OF A YEAR:
I.
STRAINING WITH MORE THAN ONE-FOURTH OF DEFECATIONS
II.
HARD STOOLWITH MORE THAN ONE-FOURTH OF DEFECATIONS
III. FEELING OF INCOMPLETE EVACUATION WITH MORE THAN ONEFOURTH OF DEFECATIONS
IV. SENSATION OF ANORECTAL OBSTRUCTION WITH MORE THAN ONEFOURTH OF DEFECATIONS
V. MANUAL MANEUVERS TO FACILITATE MORE THAN ONE-FOURTH
OF DEFECATIONS
VI. FEWER THAN THREE BOWEL MOVEMENTS PER WEEK
VII. INSUFFICIENT CRITERIA FOR IRRITABLE BOWEL SYNDROME
 PREVENTION
- CONSTIPATION IS USUALLY EASIER TO PREVENT THAN TO TREAT.
FOLLOWING THE RELIEF OF CONSTIPATION.
- MAINTENANCE WITH ADEQUATE EXERCISE, FLUID INTAKE, AND
HIGH FIBER DIET IS RECOMMENDED.
-
CHILDREN BENEFIT FROM SCHEDULED TOILET BREAKS, ONCE
EARLY IN THE MORNING AND 30 MINUTES AFTER MEALS.
 TREATMENT
- THE MAIN TREATMENT OF CONSTIPATION INVOLVES THE
INCREASED INTAKE OF WATER AND FIBER.
- THE ROUTINE USE OF LAXATIVES IS DISCOURAGED, AS HAVING
BOWEL MOVEMENTS MAY COME TO BE DEPENDENT UPON THEIR
USE.
- ENEMAS CAN BE USED TO PROVIDE A FORM OF MECHANICAL
STIMULATION.
- HOWEVER, ENEMAS ARE GENERALLY USEFUL ONLY FOR STOOL IN
THE RECTUM, NOT IN THE INTESTINAL TRACT.
LAXATIVES
- LACTULOSE AND MILK OF MAGNESIA HAVE BEEN COMPARED
WITH POLYETHYLENE GLYCOL (PEG) IN CHILDREN.
- ALL HAD SIMILAR SIDE EFFECTS, BUT PEG WAS MORE EFFECTIVE AT
TREATING CONSTIPATION.
- OSMOTIC LAXATIVES ARE RECOMMENDED OVER STIMULANT
LAXATIVES.
PHYSICAL INTERVENTION
- CONSTIPATION THAT RESISTS THE ABOVE MEASURES MAY REQUIRE
PHYSICAL INTERVENTION SUCH AS MANUAL DISIMPACTION (THE
PHYSICAL REMOVAL OF IMPACTED STOOL USING THE HANDS)
 PROGNOSIS
- COMPLICATIONS THAT CAN ARISE FROM CONSTIPATION
INCLUDE ANAL FISSURES, RECTAL PROLAPSE, AND FECAL
IMPACTION.
- STRAINING TO PASS STOOL MAY LEAD TO HEMORRHOIDS.
- IN LATER STAGES OF CONSTIPATION, THE ABDOMEN MAY BECOME
DISTENDED, HARD AND DIFFUSELY TENDER. SEVERE CASES ("FECAL
IMPACTION" OR MALIGNANT CONSTIPATION) MAY EXHIBIT SYMPTOMS
OF BOWEL OBSTRUCTION (VOMITING, VERY TENDER ABDOMEN)
AND ENCOPRESIS, WHERE SOFT STOOL FROM THE SMALL INTESTINE
BYPASSES THE MASS OF IMPACTED FECAL MATTER IN THE COLON.
HIRSCHSPRUNG`S DISEASE
 DEFINITION:-
DEFECT IN ITESTINAL MOTILITY ASSOCIATED WITH
COPLETE ABSENCE OF ENTERIC GANGELIA IN
THE INVOLVED SEGMENT OF THE COLON.
 INCIDENCE: 1:5000 LIVEBIRTH
 RATIO: 4 MALE : 1 FEMALE
 ASSOCIATED WITH:
1-DOWN SYNDROME 2- WAARDENBURG SYNDROME
3- KAUFMANN-MC SYNDROME 4- SMITH LEMLI OPTIZ SYNDROME
5- GOLDBERG SHPRINZEN SYNDROME 6- ONDINE SYNDROME
7- V-U REFLUX AND HYDROURETERS DIVERTICULUMN OF BLADDER
8-CEREBRAL A-V MALFORMATION 9- MICROCEPHALY
10- MYELOMENINGOCELE 11- MEN (TYPE 2)
BARIUM ENEMA EXAMINATION SHOWING RECTO-SIGMOID
HIRSCHSPRUNG'S DISEASE
 CLINICAL FINDING:
2/3 OF CASES DIAGNOSED AT 3 MONTHS
VERY SMALL NUMBERS OF PATIENT DIAGNOSED AFTER 5 YEARS
1ST WEEK OF LIFE:
1. PATIENT IS AVERAGE OF WEIGHT.
2. FAIL TO PASS MECONIUM
3. RELUCTANT TO FEED
4. BILIOUS VOMITING
5. ABDOMINAL DISTENSION
6. GRUNTING
INFANCY:
1. PRESENT WITH :
2. CONSTIPATION
3. ABDOMINAL DISTENSION
4. VOMITING
CHILDHOOD:
1. PRESENT WITH CONSTIPATION OFFENSIVE RIBBON-LIKE STOOL
2. ABDOMINAL DISTENSION
3. HYPOCHROMIC ANEMIA
4. HYPOPROTEINEMIA
5. ENCOPORESIS
 DIAGNOSIS:
A.
RECTAL EXAM: NARROW, EMPTY RECTUM AND AS THE FINGER IS
WITHDRAWN.
B.
X-RAY:DESTENSION OF GAS AND ABSENCE OF GAS IN PELVIS
C.
RECTAL BIOPSY: PROCEDURE OF CHOISE.
D.
MANOMETRIC STUDY: RECORDING INTERNAL AND EXTERNAL
RECTAL PRESSURE.
 TREATMENT:1.
CORRECT DEHYDRATION.
2.
CORRECT ACID-BASE PROBLEMS
3.
PARENTERAL FLUIDS
4.
CORRECT HYPOALBUMINEMIA OR ANY SHOCK
5.
RECTAL IRRIGATION BY NORMAL SALINE SOLUTION
6.
SURGERY:COLOSTOMY.
DEFFERENTIATE BETWEEN FUNCTIONAL CONSTIPATION AND HIRSCHSPRUNG
FUNCTIONAL CONSTIPATION
HIRSCHSPRUNG DISEASE
AFTER 2 YEARS
AT BIRTH
COMMON
VERY RARE
UNCOMMON
POSSIBLE
ENTEROCOLITIS
NONE
POSSIBLE
ABDOMINAL PAIN
COMMON
COMMON
ABDOMINAL DISTENSION
RARE
COMMON
POOR WEIGHT GAIN
RARE
COMMON
NORMAL
NORMAL
STOOL IN AMPULA
AMPULA EMPTY
DISTENSION OF THE RECTUM
CAUSES RELAXATION OF UNIT
SPHINCTER
NO SPHINCTER OR
PARADOXIAL RELAXATION OR
INCREASE IN PRESSURE
NORMAL
NO GANGELIA CELL
MASSIVE AMOUNT OF STOOL
NO TRANSITIONAL ZONE
INCREASE ACETYL
CHOLENSTRASE STAINING
TRANSITION ZONE, DELAYED
EVACUATION
HISTORY
ENCOPRESIS
F.T.T
EXAMINATION
ANAL TONE
RECTAL EXAM
LAB
ANORECTAL MANOMETRY
RECTAL BIOPSY
BA ENEMA