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Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
Constipation in Childrens
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Constipation in Childrens

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this presentation is all about the constipation in children, how we evaluate history and what steps should be taken for treatment.

this presentation is all about the constipation in children, how we evaluate history and what steps should be taken for treatment.

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  • A normal pattern of stool evacuation is thought to be a sign of health in children of all ages. Especially during the first months of life, parents pay close attention to the frequency and the characteristics of their children’s defecation. Any deviation from what is thought by any family member to be normal for children may trigger a call to the nurse or a visit to the pediatrician.
  • Plainabd.radiograph useful in documenting the nature of the problem to the older child and his or her parents, particularly when a history of constipation is not evident or is denied. Anorectalmanometry is sometimes helpful in delineating the child's defecation dynamics.[11 ]Many children with encopresis have evidence of megarectum, as evidenced by diminished sensation to distention of the rectum during balloon insufflation. Many children who have encopresis also have paradoxical constriction of the external anal sphincter (EAS) during attempted defecation. Anorectalmanometry can also be helpful in excluding ultrashort-segment Hirschsprung disease, which is a rare cause of encopresis. With this disorder, intramural ganglion cells in the submucosa and myenteric plexuses of the distal colon are absent. In the absence of these ganglion cells, the internal anal sphincter does not relax in response to rectal distention by balloon inflation.Procedures:Although Hirschsprung disease is rarely associated with encopresis, if suspected, this diagnosis can be excluded by identifying ganglion cells in the submucosa and myenteric plexuses of the rectum.
  • Plainabd.radiograph useful in documenting the nature of the problem to the older child and his or her parents, particularly when a history of constipation is not evident or is denied. Anorectalmanometry is sometimes helpful in delineating the child's defecation dynamics.[11 ]Many children with encopresis have evidence of megarectum, as evidenced by diminished sensation to distention of the rectum during balloon insufflation. Many children who have encopresis also have paradoxical constriction of the external anal sphincter (EAS) during attempted defecation. Anorectalmanometry can also be helpful in excluding ultrashort-segment Hirschsprung disease, which is a rare cause of encopresis. With this disorder, intramural ganglion cells in the submucosa and myenteric plexuses of the distal colon are absent. In the absence of these ganglion cells, the internal anal sphincter does not relax in response to rectal distention by balloon inflation.Procedures:Although Hirschsprung disease is rarely associated with encopresis, if suspected, this diagnosis can be excluded by identifying ganglion cells in the submucosa and myenteric plexuses of the rectum.
  • Transcript

    • 1.
    • 2. Approach to a Child with Constipation and Encopresis
      What’s Problem with me??
      Dr. SaimaBahir
      Post Graduate Trainee
      Pediatric Medicine Unit- I
    • 3. OBJECTIVE
      Causes of constipation in children
      Differentiate organic from non organic causes
      Identify red flag sign
      Plan out Investigation
    • 4. NORMAL STOOL FREQUENCY
      The normal frequency of bowel movements at different ages has been defined.
      Infants have a mean of 4 stools per day during the first week of life.
      This frequency gradually declines to a mean average of 1.7 stools per day at 2 years of age and 1.2 stools per day at 4 years of age
      Some normal breast-fed babies do not have stools for several days or longer.
      After 4 years,the frequency of bowel movements remains unchanged
    • 5. DEFINITION OF CONSTIPATION
      “A delay or difficulty in defecation, present for two or more weeks, sufficient to cause significant distress to the patient.”
      (North American Society for Pediatric Gastroenterology)
    • 6. DEFINITION OF ENCOPRESIS
      Repeated involuntary passage of feces into places not appropriate for that purpose...the event must take place for at least 6 months, the chronologic and mental age of the child must be at least 4 years
    • 7. TYPES OF ENCOPRESIS
      Retentive encopresis:
      Seepage of liquid stool around the fecal mass in a chronically distended rectum.
      Non retentive encopresis:
      The passage of stools in an inappropriate place, occurring in children aged 4 years and older, with no evidence of constipation on history or examination
    • 8. DEFINITION BY PaCCT GROUP
      The occurrence of two or more of the following
      characteristics during the past eight weeks:
      Frequency of bowel movements less than three per week
      More than one episode of faecal incontinence per week
      Large stools in the rectum or palpable on abdominal examination
      Passing of stools so large that they may obstruct the toilet
      Display of retentive posturing and withholding behaviours
      Painful defecation
    • 9. EPIDEMIOLOGY
      EPIDEMIOLOGY
      The exact worldwide prevalence in children is not known.
      0.3% to 28% of children worldwide are constipated.
      Constipation occurs in all social classes.
      Much more common in boys than in girls
    • 10. PATHOPHSIOLOGY
    • 11. E T I O L O G Y
      Intestinal muscle or nerve problem
      Hirschsprung disease
      Pseudo-obstruction (visceral myopathy or neuropathy)
      Intestinal neuronal dysplasia
      Spinal cord abnormalities:
      myelomeningocele, spina bifida, tethered cord
      Metabolic causes:
      hypothyroidism, hypercalcemia, hypokalemia,diabetesinsipidus
      Heavy-metal poisoning (lead)
      Medication side effects (vitamin D intoxication, pancreatic enzymes)
      INFANTS
      Anatomic
      Congenital anorectal malformation (Anal stenosis,Imperforateanus,Anteriorly displaced anus)
      Intestinal stricture (post necrotizing enterocolitis)
      Abnormal musculature
      Prune belly syndrome
      Gastroschisis
      Down syndrome
      Cystic fibrosis
      Cow’s milk protein intolerance
    • 12. Spinal cord abnormalities:
      Spinal cord trauma, tumor
      Metabolic causes:
      hypothyroidism, hypercalcemia, hypokalemia, diabetes mellitus, diabetes insipidus
      Neurological
      Neurofibromatosis
      Developmental delays
      Heavy-metal poisoning (lead)
      Medication side effects (vitamin D intoxication, pheno, antihypertensive, pancreatic enzymes, antidepressants, chemo vincristine)
      Connective Tissue Disorders Systemic lupus Erythematosus
      Scleroderma
      Psychiatric Diagnosis
      Anorexia nervosa
      Spinal cord abnormalities:
      Spinal cord trauma, tumor
      Metabolic causes:
      hypothyroidism, hypercalcemia, hypokalemia, diabetes mellitus, diabetes insipidus
      Neurological
      Neurofibromatosis
      Developmental delays
      Heavy-metal poisoning (lead)
      Medication side effects (vitamin D intoxication, pheno, antihypertensive, pancreatic enzymes, antidepressants, chemo vincristine)
      Connective Tissue Disorders Systemic lupus Erythematosus
      Scleroderma
      Psychiatric Diagnosis
      Anorexia nervosa
      Children more than 1yr
      Functional constipation in more than 95%
      Anatomic
      Intestinal stricture (post necrotizing enterocolitis)
      Abnormal musculature
      Down syndrome
      Intestinal disorder
      Cystic fibrosis
      Gluten enteopathy
      Inflammatory bowel disease (strictures)
      Tumors
      Intestinal muscle or nerve
      problem
      Hirschsprung disease
      Cow’s milk protein intolerance
    • 13. Children more than 1yr
      Functional / Non-organic causes
      Developmental
      Cognitive handicaps
      Attention-deficit disorders
      Situational
      Coercive toilet training
      Toilet phobia
      School bathroom avoidance
      Excessive parental interventions
      Sexual abuse
      Other
      Depression
      Constitutional
      Colonic inertia
      Genetic predisposition
      Reduced stool volume and dryness
      Low fiber in diet
      Dehydration
      Underfeeding or malnutrition
    • 14. EVALUATION
      History
      Physical examination
      Investigation
      To identify organic causes for constipation
      Identify red flag signs
    • 15. HISTORY
      HISTORY
      Age and Sex
      Chief symptom
      Constipation history
      Frequency and consistency of stools
      Pain or bleeding with passing stools
      Abdominal pain
      Waxing and waning of symptoms
      Age of onset
      Toilet training
      Fecal soiling
      Withholding behavior
      Change in appetite
    • 16. Nausea or vomiting
      Weight loss
      Perianal fissures, dermatitis, abscess, or fistula
      Current treatment
      Current diet (24-hour recall history)
      Current medications (for all medical problems)
      Oral, enema, suppository, herbal
      Previous treatment
      Diet
      Medications: Oral, enema, suppository, herbal
      Prior successful treatments
      Behavioral treatment
      Results of prior tests
      Estimate of parent/patient adherence
    • 17. Medical history
      Gestational age
      Time of passage of meconium
      Condition at birth
      Acute injury or disease
      Hospital admissions
      Surgeries
      Delayed growth and development
      Features of hypothyroidism: Sensitivity to cold, Coarse hair, Dry skin
      Recurrent urinary tract infections
      Daytime urinary incontinence
      Developmental history
      Normal, delayed
      School performance
    • 18. Detailed dietary history
      Psychosocial history
      Psychosocial disruption of child or family
      Interaction with peers
      Temperament
      Toilet habits at school
      Family history
      Significant illnesses
      Gastrointestinal (constipation, Hirschsprung disease)
      Thyroid, parathyroid, cystic fibrosis, celiac disease
    • 19. PHYSICAL EXAMINATION
      PHYSICAL EXAMINATION
      General appearance
      Vital signs
      Temperature
      Pulse
      Respiratory rate
      Blood pressure
      Growth parameters
      Head, ears, eyes, nose, throat
      Neck (goiter, lymhnodes)
      General appearance
      Vital signs
      Temperature
      Pulse
      Respiratory rate
      Blood pressure
      Growth parameters
      Head, ears, eyes, nose, throat
      Neck (goiter, lymhnodes)
    • 20. PHYSICAL EXAMINATION
      PHYSICAL EXAMINATION
      General appearance
      Vital signs
      Temperature
      Pulse
      Respiratory rate
      Blood pressure
      Growth parameters
      Head, ears, eyes, nose, throat
      Neck (goiter, lymhnodes)
      Abdomen
      Distension
      Palpable liver and spleen
      Fecal mass
      Anal inspection
      Position
      Stool present around anus or on clothes
      Perianalerythema
      Skin tags
      Anal fissures
      Rectal examination
      Anal tone
      Fecal mass
      Presence of stool
      Consistency of stool
      Other masses
      Explosive stool on withdrawal of finger
    • 21. PHYSICAL EXAMINATION
      PHYSICAL EXAMINATION
      General appearance
      Vital signs
      Temperature
      Pulse
      Respiratory rate
      Blood pressure
      Growth parameters
      Head, ears, eyes, nose, throat
      Neck (goiter, lymhnodes)
      Back and spine examination
      Dimple
      Tuft of hair
      Neurological examination
      Tone
      Strength
      Cremasteric reflex
      Deep tendon reflexes
      Cardiovascular
      Lungs and chest
    • 22. RED FLAG SIGN FOR ORGANIC DISEASE
      Failure to thrive
      Abdominal distension
      Pilonidal dimple covered by a tuft of hair
      Midline pigmentary abnormalities of the lower spine
      Lack of lumbosacral curve
      Sacral agenesis
      Flat buttocks
      Anteriorly displaced anus
      Patulous anus
    • 23. Red flag sign for organic disease
      Tight, empty rectum in presence of palpable abdominal fecal mass
      Gush of liquid stool and air from
      rectum on withdrawal of finger
      Occult blood in stool
      Absent anal wink
      Absent cremasteric reflex
      Decreased lower extremity tone and/or strength
      Absence or delay in relaxation phase of lower extremity deep-tendon reflexes
    • 24. FINDINGS CONSISTENT WITH FUNCTIONAL CONSTIPATION
      History
      Stool passed within 48 hours of birth
      Extremely hard stools, large-caliber stools
      Fecal soiling (encopresis)
      Pain or discomfort with stool passage; withholding of stool
      Blood on stools; perianal fissures
      Decreased appetite, waxing and waning of abdominal pain with stool passage
    • 25. Findings consistent with functional constipation
      Diet low in fiber or fluids, high in dairy products
      Hiding while defecating before toilet training is completed; avoiding the toilet
      Physical examination
      Mild abdominal distention; palpable stool in left lower quadrant
      Normal placement of anus; normal anal sphincter tone
      Rectum packed with stool; rectum distended
      Presence of anal wink and cremasteric reflex
    • 26. INVESTIGATION
      Most children require no investigation
      CBC
      Plain radiograph of abdomen for fecal impaction
      Stool examination for occult blood
      Other specific test
      Barium enema
      Colonoscopy
      Hirshprung disease
      Barium enema in unprepared gut
      Rectal biopsy
      Anorectalmanometry
    • 27. INVESTIGATION
      Thyroid function test
      Celiac antibodies
      Serum electrolyte (Na, K, Ca)
      Spinal cord problem
      X-ray spine
      MRI Spine
      Cystic fibrosis
    • 28. Infant with signs or symptoms suggestive of constipation
      Red flag sign for organic disease
      yes
      No
      Evaluate for organic disease
      Diagnosis for functional constipation
    • 29. ENCOPRESIS
    • 30. PATHOPHSIOLOGY OF ENCOPRESIS
      In the vast majority of cases, encopresis develops as a consequence of chronic constipation with resulting overflow incontinence which is typically termed retentive encopresis.
      Boys are more commonly effected.
    • 31. CAUSES
      95% of cases no organic cause
      Constipation 80%
      Non retentive 20%
      Anorectal malformation
      Spinal cord problem
      Meningomyelocele
      Spina bifid
    • 32. HISTORY
      Age and Sex
      Soiling history
      Age of onset of symptom
      Age of bowel and bladder control
      Toilet trained for more than 6 mon
      Frequency-Episodes per week or month
      Time of the day (day, night, school)
      Constipation
      Pain with defecation
      Treatment taken and effectiveness
    • 33. HISTORY
      Medical history
      Delayed meconium passage
      Any previous illness
      Spinal cord problem
      Developmental history
      Detailed dietary history
      Psychosocial history
      Psychosocial disruption of child or family
      Interaction with peers
    • 34. HISTORY
      Approximately 80-95% of children with encopresis have a history of constipation or painful defecation.
      In most cases, soiling episodes occur during the daytime when the child is awake and active. Soiling at night when the child is asleep is uncommon.
      As evidence of functional megacolon, many children with retentive encopresis intermittently pass extremely large bowel movements.
    • 35. EXAMINATION
      Physical findings, other than those obtained from the abdominal and rectal examinations, are usually normal.
      Abdominal examination:
      Stool can be palpated most notably in left lower quadrant.
      Rectal examination:
      Anal tone
      Fecal mass
      Consistency of stool
      Explosive stool on withdrawal
      of finger
      Neurologic findings:
      Anal wink
      Sensation, strength, and reflexes in
      the lower extremities.
    • 36. INVESTIGATION
      In most patients, the diagnosis of encopresis is established with the history and complete physical examination, including a rectal examination.
      Laboratory studies are rarely warranted.
      Plain abdominal radiograph
      Soft fecal impaction
      Anorectalmanometry
      Rectal biopsy
    • 37. ?
    • 38.
    • 39. THANK YOU

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