Approach to a Child with Constipation and Encopresis<br />What’s Problem with me??<br />Dr. SaimaBahir<br />Post Graduate ...
OBJECTIVE<br />Causes of constipation in children<br />Differentiate organic from non organic causes<br />Identify red fla...
NORMAL STOOL FREQUENCY<br />The normal frequency of bowel movements at different ages has been defined.<br />Infants have ...
DEFINITION OF CONSTIPATION<br />“A delay or difficulty in defecation, present for two or more weeks, sufficient to cause s...
DEFINITION OF ENCOPRESIS<br />Repeated involuntary passage of feces into places not appropriate for that purpose...the eve...
TYPES OF ENCOPRESIS<br />Retentive encopresis:<br />Seepage of liquid stool around the fecal mass in a chronically distend...
DEFINITION BY PaCCT GROUP<br />The occurrence of two or more of the following<br />characteristics during the past eight w...
EPIDEMIOLOGY<br />EPIDEMIOLOGY<br />The exact worldwide prevalence in children is not known. <br />0.3% to 28% of children...
PATHOPHSIOLOGY<br />
E T I O L O G Y<br />Intestinal muscle or nerve problem<br />Hirschsprung disease<br />Pseudo-obstruction (visceral myopat...
Spinal cord abnormalities:<br />Spinal cord trauma, tumor<br />Metabolic causes:<br />	hypothyroidism, hypercalcemia, hypo...
Children more than 1yr<br />Functional / Non-organic causes<br />Developmental<br />Cognitive handicaps<br />Attention-def...
EVALUATION<br />History<br />Physical examination<br />Investigation<br />To identify organic causes for constipation<br /...
HISTORY<br />HISTORY<br />Age and Sex<br />Chief symptom<br />Constipation history<br />Frequency and consistency of stool...
Nausea or vomiting<br />Weight loss<br />Perianal fissures, dermatitis, abscess, or fistula<br />Current treatment<br />Cu...
Medical history<br />Gestational age<br />Time of passage of meconium<br />Condition at birth<br />Acute injury or disease...
Detailed dietary history<br />Psychosocial history<br />Psychosocial disruption of child or family<br />Interaction with p...
PHYSICAL EXAMINATION<br />PHYSICAL EXAMINATION<br />General appearance<br />Vital signs<br />Temperature<br />Pulse<br />R...
PHYSICAL EXAMINATION<br />PHYSICAL EXAMINATION<br />General appearance<br />Vital signs<br />Temperature<br />Pulse<br />R...
PHYSICAL EXAMINATION<br />PHYSICAL EXAMINATION<br />General appearance<br />Vital signs<br />Temperature<br />Pulse<br />R...
RED FLAG SIGN FOR ORGANIC DISEASE<br />Failure to thrive<br />Abdominal distension<br />Pilonidal dimple covered by a tuft...
Red flag sign for organic disease<br />Tight, empty rectum in presence of palpable abdominal fecal mass<br />Gush of liqui...
FINDINGS CONSISTENT WITH FUNCTIONAL CONSTIPATION<br />History<br />Stool passed within 48 hours of birth<br />Extremely ha...
Findings consistent with functional constipation<br />Diet low in fiber or fluids, high in dairy products<br />Hiding whil...
INVESTIGATION<br />Most children require no investigation<br />CBC<br />Plain radiograph of abdomen for fecal impaction<br...
INVESTIGATION<br />Thyroid function test<br />Celiac antibodies<br />Serum electrolyte (Na, K, Ca)<br />Spinal cord proble...
Infant with signs or symptoms suggestive of constipation<br />Red flag sign for organic disease<br />yes<br />No<br />Eval...
ENCOPRESIS<br />
PATHOPHSIOLOGY OF ENCOPRESIS<br />In the vast majority of cases, encopresis develops as a consequence of chronic constipat...
CAUSES<br />95% of cases no organic cause<br />Constipation 80%<br />Non retentive 20%<br />Anorectal malformation<br />Sp...
HISTORY<br />Age and Sex<br />Soiling history<br />Age of onset of symptom<br />Age of bowel and bladder control<br />Toil...
HISTORY<br />Medical history<br />Delayed meconium passage<br />Any previous illness<br />Spinal cord problem<br />Develop...
HISTORY<br />Approximately 80-95% of children with encopresis have a history of constipation or painful defecation.<br />I...
EXAMINATION<br />Physical findings, other than those obtained from the abdominal and rectal examinations, are usually norm...
INVESTIGATION<br />In most patients, the diagnosis of encopresis is established with the history and complete physical exa...
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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.

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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&apos;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&apos;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.
  • Constipation in Childrens

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