Chronic Constipation and Encopresis

1. Chronic Constipation and Encopresis Susan Ratliff, MD FAAP April 2, 2009

3. Constipation • Abnormality in the frequency of defecation or in the size or consistency of the feces • Range of symptoms and signs • Consider constipation a symptom instead of a diagnosis

4. Constipation • ¼ all cases of chronic constipation begin during the first year of life, highest frequency occurring between ages 2 and 4 • Males:females 1.5:1 • Most cases have no precipitating factor

5. History • Normal frequency of defecation • Size • Consistency of stools passed at different stages

6. Stool Frequency • Defecation rate higher in breastfed than formula fed infants in early infancy • By 4 mos all infants have a modal frequency of two bowel movements per day • Frequency declines to the “adult” pattern of one stool per day by school • 96% of 3-4 yr olds have bowel movements between 3 times per day and 3 times per week

7. Symptoms • Abdominal pain • irritability • Anorexia • Abdominal distention • Diarrhea • Encopresis

8. Physical exam • Abdominal exploration • Exploration of the sacral region • Exploration of the anorectal region • KUB not indicated to establish the presence of fecal impaction if the rectal exam reveals the presence of large amounts of stool

10. Organic causes of constipation • Minority of children but should be recognized early • History!!! • Early onset of constipation (first days of life) • Severe constipation unaffected by medical therapy • Associated features such as vomiting, persistent abdominal distention an failure to thrive

11. Organic causes of constipation • Anatomic disorders of colon and anorectum • Congenital anal stenosis • Severe chronic fecal retention • Symptoms from an early age • Pass small stools • Anterior displacement of anal orifice • Onset early infancy • Normal sphincter but abnormally oblique direction of anal canal • Intraspinal problems • Tethered cord, tumors or sacral agenesis • Congenital or acquired colonic strictures • NEC or inflammatory bowel disease

12. Organic causes of constipation • Motility disorders • Hirschprungs disease • Congenital absence of ganglion cells in the myenteric and submucosal plexuses of the GI tract • 1:5000 live births; male:female ratio 3:1 • Misc systemic disorders • Hypothyroidism • Pheochromocytoma • Hypercalcemia • Lead poisoning • Cystic Fibrosis

13. Functional constipation • Most common cause • Occurs during dietary transition • Weaning in infancy • Early childhood • Any age? • Most commonly caused by painful bowel movements with resultant voluntary withholding of feces • Prevention with appropriate diet and adequate intake of fluids

14. Withholding • Prolonged faces stasis in the colon, with reabsorption of fluids in an increase in the size and consistency of the stools • Leads to passage of hard stools that painfully stretch the anus • This leads to fearful determination to avoid all defecation • With time this becomes an automatic reaction • The rectal wall stretches and fecal soiling may occur • After several days, irritability, abdominal distention, cramps, and decreased oral intake may result

16. 1 yr prospective study of 2144 children <5 yrs of age referred to outpatient clinic with constipation • 48% had history of hard stool, all but three received laxatives • 50% were treated with suppositories, enemas or combination of both

17. Lack of structure in management of constipation in preschool children • Time lapse between onset of symptoms and referral to a specialist • Reluctance to increase laxative treatment • Failure to address parents’ anxieties

19. Contributing factors • Emotional distress • Family distress • Illness • Dietary switch from human to cow’s milk • Lack of dietary fiber • Changes in Environment • Travel • Drugs

20. Drugs that can cause constipation • Analgesics (NSAIDS) • Anticholinergics • Calcium Channel Blockers • Iron Supplements • Lead Poisoning • Opiates • Tricyclic antidepressants

22. Encopresis • Involuntary defecation of psychogenic origin • More common in males • Usually appears in children over 4 yrs of age, avg age 4 yrs 7 mos • Associated with recurrent uti and enuresis (disappear when intestinal problems corrected)

23. Encopresis • Need more rigorous therapeutic program for treatment • Initial objective is to keep the rectum empty in order to diminish its size, increase rectal sensibility to distention and avoid encopresis

24. Encopresis • First step: rectal disimpaction • Hypertonic phosphate enemas or bissacodyl suppositories until evacuation without solid feces • Second step: prevent reaccumulation of retained feces and prevent reoccurrence of encopresis • Osmotic laxatives or stimulants or mineral oil in high doses • Develop a regular defecation schedule • Take advantage of the gastrocolic reflex (5-15 mins) • Manometric feedback?

26. Treatment • Dietary changes • Bulk forming agents • Lubricants • Hyperosmolar agents

27. Dietary management • High fiber diet • Age + 5= grams of fiber per day • Increase amount gradually to prevent side effects • Fruits, breads and cereals • Fluid intake

28. Bulk-forming agents • Increase bulk of the nonabsorbable portion of the intestinal contents to increase the stimulus for peristalsis mimicking the normal course of defecation

29. Stimulant agents • Increase the irritability of the intestinal muscle so that it responds more to distention

30. Lubricants • Soften the feces and ease defecation • Do not initiate defecation

31. Hyperosmolar Agents • Increase the intestinal volume via an osmotic effect

32. Treatment • Simple Constipation • Dietary measures, bowel habit training • Prolonged Constipation • As above • Low dose mineral oil, senna or lactulose • Chronic Constipation with Mega rectum and encopresis • Fecal disimpaction with phosphate enemas or bisacodyl suppositories • Dietary measures, bowel habit training, high dose mineral oil, lactulose or miralax, psychological support • Voluntary fecal incontinence • Psychologic evaluation and treatment

33. Stepwise approach to treatment • Step one: Diet and regular bowel habits • Step two: Produce a natural course of defecation with bulk-forming agents or ease defecation with stool softeners • Step three: Stimulant laxatives for resistant cases

34. Route of administration • First step should be oral agents; reserve rectal route for fecal impaction

35. Treatment of infants • Increased intake of fluids, particularly juices with sorbitol (prune, pear and apple) • Lactulose, Karo syrup, sorbitol can be used • Glycerin suppositories • Avoid mineral oil in very young • Lipoid pneumonia

36. Pediatric dosages of laxatives

38. Behavioral Modifications • Regular toilet habits • Unhurried time on the toilet after meals • Diaries of stool frequency combined with a reward system • Referral to mental health provider for behavior modification • Requires family that is well organized, can complete time consuming interventions and is sufficiently patient to endure gradual improvements and relapses

39. Maintenance therapy • Mineral oil, sorbitol or MOM • 1-3 cc/kg/day • PEG 3350 2 tsp/ 8 oz liquid qd-tid • May be necessary for several months • Only consider discontinuation when the child has been having regular bowel movements without difficulty • Relapses are common!

40. Prevention • Counsel parents on normal defecation habits • Introduce good dietary habits • Adequate intake of liquids with only moderate consumption of milk • Balanced fiber-rich diet

41. References • Lowe, Julie and Bruce Parks. “Movers and Shakers: A clinician’s guide to laxatives.” Pediatric Annals. 1999 (307-310). • Weaver, Lawrence. “Constipation: Diagnosis and treatment.” Seminars in Pediatric Gastroenterology and Nutrition. Vol 3: Number 4. 1992. (1-14). • Baker, Susan et al. “Constipation in Infants and Children: Evaluation and Treatment.” Journal of Pediatric Gastroenterology and Nutrition. 29:612-626. • Motivational poop posters • www.oxypowder.com