Good Morning!

1. Good Morning! Tuesday, April 3rd 2012

2. Causes of Constipation

3. Causes of Constipation

5. 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) • 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

6. 90% of newborns pass meconium in 1st 24 hours • Intestinal transit time • 8 hours = 1 month • 16 hours = 2 years • 26 hours = 10 years • 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

7. 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 Vicious cycle of constipation

8. 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: • Introduction of cereals and solid foods • Toilet training • Start of school Functional Constipation

9. Toddlers and older children may withhold stool: • Painful defecation • Avoid defecation in a strange toilet away from home • Too distracted (ADHD) • Symptoms: • Early satiety, desire to eat small volumes all day, increasing irritability, spasms of abdominal pain in lower abdomen Functional Constipation (cont’d)

10. 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: • 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

11. 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

12. Growth and weight gain • Umbilical girth • Abdominal exam • Bowel sounds • Palpable dilated loops • Rectal exam • Distended rectum full of stool • Back (look for sacral skin findings) Physical Exam

13. Plain abdominal radiograph • Thyroid function, electrolyte levels, magnesium • *UA, urine culture • Lumbosacral spine films/MRI • Barium enema • Lead level • Motility testing • Colon transit studies • Anorectalmanometry • Consider in pts. with no organic cause of constipation, but failure to respond to aggressive treatment Laboratory

14. 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

15. Hirschsprung Disease

16. Repeated involuntary fecal soiling in the underpants • Children should obtain fecal continence by the age of 4 • *Encopresis is a symptom rather than a developmental variation after age 4 to 5 • 90% is functional • Retentive constipation with overflow incontinence • *5 to 10% is organic, behavioral, environmental (privacy issues) • Anatomic, neurologic, metabolic, iatrogenic Encopresis

17. Phase 1: Disimpaction Management of Chronic Constipation and Encopresis

18. 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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20. 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

21. Anorectaldyssynergia • Paradoxic increase in external sphincter tone while trying to defecate • Diagnosed with anorectalmanometry • Patients are candidates for biofeedback therapy with manometry Behavior Modification

22. 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

23. 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 • Probiotics • Have been shown to improve colonic transit time • More studies are needed Management of Chronic Constipation and Encopresis

24. Patients who show no improvement after 6 months should be referred to GI • *Relapses are common! • Rates of recurrence approach 50% Relapse