Chronic Constipation Update in Managment - ppt8

Chronic
Constipation:
Update in
Management
Abdulwahab Telmesani
FRCPC,FAAP
Faculty of Medicine and
Medical Science
Umm Al-Qura University
Chronic constipation
3%
of the visits to general pediatrics.

25% of the visits to pediatrics G.I.
Definition
Infrequent
Hard
stool
stool
Large stool
Definition
NASPGAN:
A delay or difficulty in defecation
present for 2 or more weeks and
sufficient to cause significant distress
to the patient.
Normal frequency of bowel

movement
Epidemiology:
The prevalence of childhood constipation
in the general population ranged from
0.7% to 29.6%
Maartje M. et al
Am J Gastroenterol 2006
Epidemiology:
constipation correlated with low maternal
education, female sex, living in a large
community and having no older siblings.
JONAS F et. al. Acta Pdiatrica,
2006
Exclusive breast fed

babies
In conclusion, infrequent bowel movements in
young infants fed exclusively breast milk can
be a harmless phenomenon that can easily
diagnosed by history and careful examination
of the infant.
Yon Ho Choe et al Eur J Pediatr
(2004)
Functional constipation in
infants: a follow-up study
We conclude that most infants with severe
constipation evaluated at a tertiary center are
recovered after 6 months. Early therapeutic
intervention may beneficially contribute to the
resolution of constipation.
van den Berg MM et al J Pediatr
2005
Trend in family / Genetic

Prominent
family history of constipation.

Identical twins have 6 times folds
possibility than non identicals.
Chronic constipation
Functional
/ non organic is most
common
Organic is rare ( except in infancy)
Functional / non organic

constipation
What cause it / start it?
Functional / non organic

constipation
Inappropriate
toilet training
Anal fissure / Anusitis
Avoidance of response to nature call
Inconvenient / uncomfortable places
Behavioral
Vicious cycle of retention development.
Encopresis:
Incontinence of stool of non organic
Origin (rare before 3 years)
Organic Causes of
Chronic constipation:
What are the causes?
Chronic constipation in
children: Organic disorders
are a major cause
A significant number of the children with
chronic treatment-resistant constipation may
have organic causes (slow colonic transit and
outlet obstruction) and suggests new
approaches to the management of children
with chronic treatment-resistant constipation.
BR Southwell et al J. Paediatr. Child Health
(2005)
Stool withholding presenting as a cause of

non-epileptic seizures
Anthony Cohn
Developmental
Medicine and Child Neurology; Oct 2005
chronic constipation and

food hypersensitivity
An increasing number of reports suggest a
relationship between refractory chronic
constipation and food allergy in children.
CARROCCIO & G. IACONO
Alimentary Pharmacology & Therapeutics 2006
Evaluation
Evaluation
History.
Physical
examination.
History:
Meconium passage.
Frequency of bowel movement.
Diet.
School / travel.
Painful defecation.
Family history.
FTT.
Clogging of the commode.
Physical examination:
Growth
Abd.
Distention
Fecal mass felt on abd. exam.
Rectum full of stool
Fecal soiling.
Anogenital index
Anogenital index:
Distance in centimeters:
from the vagina or scrotum to the anus
_______________________________
from the vagina or scrotum to the coccyx.
Females: 0.39 0.09,
Males:
0.56 0.2.
Physical examination:
Anal
fissure / anusitis.
Signs of trauma (abuse).
Signs of spinal defects( spina bifida)
Neurological assessment of L.L. and
anal wenk
Myelomeningocele
Spina bifida
Tethered cord syndrome
Neurofibromatosis
Investigations
Investigations:
Non is required routinely.
Investigations:
Stool analysis ??? Whyyyy
Investigations:
Plain
abdominal X RAY. ( obese child

or refusing exam)
Lumbosacral X RAY / MRI
Ba. Enema
Rectal biopsy.
T4, Na, K, Osmolality.
Investigations:
Anorectal
manometry.
Anal sphincter EMG.
Defecography.
Colorectal transit study.
Management
Management:
Evaluation and Treatment of Constipation in
Infants and Children: Recommendations of
the North American Society for Pediatric
Gastroenterology, Hepatology and Nutrition
[Clinical Practice Guideline]
J Pediatr Gastroenterol Nutr 2006 Sep; Vol.
43 (3), pp. e1-13.
Management:
Education.
Disimpaction.
Maintenance.
Behavioral
modification.
Education:
Educate the family and the child if
possible:
Pathophysiology
That
incontinence is not willful.

Use drawings to explain.
Disimpaction:
Fecal impact evacuation:
Phosphate
enema (fleet enema)

Oral medication e.g. mineral oil
(paraffin oil), polyethylene glycol
(PEG3350) or both
Maintenance:
Mieral
oil (paraffin oil); 1-3 ml/kg/day
Polyethylene
glycol (PEG 3350)

electrolyte free; 1 g/kg/day
Maintenance:
Lactulose,
Mg hydroxide, Sorbitol,
others have been used
On and off laxatives e.g. Senna
Maintenance:
In
case of anal fissure, apply

petroleum gel to anal area
frequently
Maintenance:
Increase dietary fibers
Prune ((
Pear juice
Apple juice
A comparative study: The efficacy

of
liquid paraffin and Lactulose in
management of chronic functional
constipation
Liquid paraffin is more effective in the treatment

of children with constipation.
NAFIYE URGANCI et al
Pediatrics International (2005)
Behavioral modification:
Regular
toilet habit (after meals)

Keep diary and record (use calendar
and stars)
Motivation (avoid negative comments)
Consultation with
specialist:
Pediatric
G.I. (Celiac disease, etc.)

Endocrine (hypothyroidism, etc.)
Nephrology (diabetes insipidus)
Pediatric surgery (Herschsprung)
Biofeedback:
Lack of coordinated relaxation of
external sphincter while defecation
On manometry
Biofeedback:
There is no evidence that biofeedback
training adds any benefit to conventional
treatment in the management of
functional fecal incontinence in children
Brazzelli, M et al
The Cochrane
Library, Copyright 2006
Surgical Treatment:
Anorectal
myectomy
The Malone appendicocecosomy (for
retrograde irrigation)
Long-Term Outcome of
Functional Childhood
Constipation
Childhood constipation appears to be a
predictor of IBS in adulthood.
Seema Khan et al
Digestive
Diseases & Sciences; Jan 2007
Thank you
Hirschsprung Disease
Pathophysiology: Hirschsprung disease results
from the absence of parasympathetic ganglion
cells in the myenteric and submucosal plexus
of the rectum and/or colon.
Frequency In the US: Hirschsprung disease occurs

in approximately 1 per 5000 live births.

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Chronic

of the visits to general pediatrics.

Normal frequency of bowel

Exclusive breast fed

Trend in family / Genetic

family history of constipation.

/ non organic is most

Functional / non organic

Functional / non organic

Stool withholding presenting as a cause of

chronic constipation and

Alimentary Pharmacology & Therapeutics 2006

Tethered cord syndrome

abdominal X RAY. ( obese child

incontinence is not willful.

enema (fleet enema)

oil (paraffin oil); 1-3 ml/kg/day

glycol (PEG 3350)

case of anal fissure, apply

A comparative study: The efficacy

Liquid paraffin is more effective in the treatment

toilet habit (after meals)

G.I. (Celiac disease, etc.)

Frequency In the US: Hirschsprung disease occurs

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