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Encopresis

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definition,causes ,diagnosis ,managment

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  • 1. Encopresis Prof. Saad S Al-Ani Senior Pediatric Consultant Head of Pediatric Department Khorfakkan Hospital Sharjah ,UAE
  • 2. Encopresis
    • Refers to the passage of feces into inappropriate places after a chronologic age of 4 yr (or equivalent developmental level).
    • Subtypes include:
    • 1. Retentive encopresis:
    • Encopresis with constipation and overflow
    • incontinence
    • 2. Nonretentive encopresis:
    • Encopresis without constipation and overflow
    • incontinence
  • 3. Encopresis (cont.)
    • Encopresis may be:
    • 1.Primary: persist from infancy onward
    • 2.Secondary : may appear after successful toilet training
    • About two thirds of encopresis cases are of the retentive type and associated with chronic constipation;
  • 4. Encopresis (cont.)
    • In children younger than 4 yr of age, the male: female ratio for chronic constipation is 1:1 .
    • In the school-aged child , however, encopresis is more common in males
  • 5. Clinical Manifestations
    • The first consideration in managing encopresis is assessment of fecal retention .
    • Rectal examination
    • * A positive rectal examination is sufficient to
    • document fecal retention
    • * A negative rectal examination in the presence of
    • encopresis requires plain abdominal
    • roentgenograms .
    • The presence of fecal retention is evidence of chronic constipation
  • 6. Clinical Manifestations (cont.)
    • Many children with encopresis present with abnormal anal sphincter physiology as documented either by electromyography or difficulty in defecating a rectal balloon.
    • The inability to defecate a balloon at presentation is associated with poorer response to treatment
  • 7. Clinical Manifestations (cont.)
    • Abnormal anal sphincter function is a marker for chronic constipation ; children with this pathology do not appear to have a higher incidence of behavioral or psychiatric disorders than those without. However, a chart review study suggests that
    • Primary encopresis in boys is associated with global developmental delays and enuresis ,
    • Secondary encopresis is associated with high levels of psychosocial stressors and conduct disorder
  • 8. Clinical Manifestations (cont.)
    • Associated behavioral or psychiatric problems obviously may complicate the treatment of encopresis,especially when parents respond to soiling with retaliatory, punitive measures and children become angry , ashamed , and resistant to intervention.
    • School performance and attendance may be secondarily affected as the child becomes the target of scorn and derision from schoolmates because of the offensive odor
  • 9. Treatment
    • The standard treatment approach to encopresis begins with
    • 1. Clearance of impacted fecal material
    • 2. Short-term use of mineral oil or laxatives to
    • prevent further constipation.
    • Concomitant behavioral management is also indicated.
    • The focus of behavioral treatment should be on compliance with:
    • 1. Regular postprandial toilet sitting and
    • 2. adoption of a high-fiber diet .
  • 10. Treatment (cont.)
    • On some occasions, manual disimpaction is required before the treatment can begin; rarely megacolon is observed and referral to a gastroenterologist is required.
    • Once impacted stool is removed, the combination of constipation management and simple behavior therapy is successful in the majority of cases , though it is often a period of months before soiling stops completely
  • 11. Treatment (cont.)
    • Parents should be actively encouraged to issue rewards for compliance to the child from the outset of treatment and to avoid power struggles with the child.
    • Keeping records of the child's progress is necessary
    • Long-term laxative use is contraindicated .
  • 12. Treatment (cont.)
    • Improvement in some children on tricyclic antidepressants
    • Tricyclic antidepressants often cause or exacerbate constipation and should be avoided in children with retentive encopresis
    • Encopresis eventually resolves in most children, regardless of treatment approach .
  • 13. Summary
    • Encopresis refers to the passage of feces into inappropriate places after a chronologic age of 4 yr
    • Subtypes include: Retentive encopresis and Nonretentive encopresis
    • Encopresis may be: Primary or Secondary
    • The first consideration in managing encopresis is assessment of fecal retention .
  • 14. Summary (cont.)
    • Primary encopresis in boys is associated with global developmental delays and enuresis ,
    • Secondary encopresis is associated with high levels of psychosocial stressors and conduct disorder
    • the combination of constipation management and simple behavior therapy is successful in the majority of cases
  • 15. References
    • Mikkelsen EJ: Enuresis and encopresis: Ten years of progress. J Am Acad Child Adolesc Psychiatry 2001;40:1146. Medline Similar articles
    • Schum TR, McAuliffe TL, Simms MD, et al: Factors associated with toilet training in the 1990s. Ambulatory Pediatrics 2001;1:79. Medline Similar articles
    • Youssef NN, Di Lorenzo C: Childhood constipation: Evaluation and treatment. J Clin Gastroenterol 2001;33:199-205. Medline Similar articles
    • Gereige RS, Frias JL: Is it more than just constipation? Pediatrics 2001;109:961-65.
    • Penning C, Gielkens HA, Hemelaar M, et al: Prolonged ambulatory recording of antroduodenal motility in slow-transit constipation. Br J Surg 2000;87:211-17. Medline Similar articles