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Pediatric Constipation

Constipation is a common gastrointestinal issue in children. It can be functional or organic in nature, with functional constipation making up the majority of cases. The document discusses the definition, epidemiology, risk factors, evaluation, and management of pediatric constipation. Evaluation involves history, physical exam, and potential imaging and testing. Management is multi-pronged, focusing on education, dietary changes, behavioral modifications, disimpaction if needed, and long-term maintenance therapy often involving laxatives. Surgery is rarely needed and reserved for severe, refractory cases. Childhood constipation can sometimes predict irritable bowel syndrome in adulthood.

1 of 52
Constipation In Pediatric Age
Group
Dr. Arjun A. Pawar
MBBS, MS,
M. Ch. Pediatric Surgery,
DNB Pediatric Surgery,
FMAS,
FIAGES, DCC
Objectives
Define “constipation”
Classification
Etiology
Risk factors
Clinical Evaluation
Investigations
Management
Constipation- Epidemiology:
• Major gastrointestinal disorder diagnosed in clinical
practice
• One of the common cause of Abdominal pain
• Prevalence of childhood constipation:12 to 19%
(Ref: Sinclair M. The use of abdominal massage to treat chronic constipation. J. Bodyw.
Mov. Ther. 2011;15:436–445. doi: 10.1016/j.jbmt.2010.07.007.)
• Pathophysiology- Complex & Multifactorial
• Common in patients with positive family history
Genetics is not known
• Identical twins have 6 folds possibility than non identical
twins.
Normal frequency of bowel
movement
Chronic Constipation
Definition
Rome 4 Criteria
Ref: Lacy B.E., Mearin F., Chang L., Chey W.D., Lembo A.J., Simren M., Spiller R.
Bowel disorders. Gastroenterology. 2016;150:1393–1407.e5.
doi: 10.1053/j.gastro.2016.02.031.
In Infants Up to 4 Years
Must include 1 month of at least 2 of the following
• 2 or fewer defecations per week
• History of excessive stool retention
• History of painful or hard bowel movements
• History of large-diameter stools
• Presence of a large fecal mass in the rectum
In toilet-trained children:
• At least 1 episode/week of incontinence after the
acquisition of toileting skills
• History of large-diameter stools that may obstruct the
toilet

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Pediatric Constipation

  • 1. Constipation In Pediatric Age Group Dr. Arjun A. Pawar MBBS, MS, M. Ch. Pediatric Surgery, DNB Pediatric Surgery, FMAS, FIAGES, DCC
  • 3. Constipation- Epidemiology: • Major gastrointestinal disorder diagnosed in clinical practice • One of the common cause of Abdominal pain • Prevalence of childhood constipation:12 to 19% (Ref: Sinclair M. The use of abdominal massage to treat chronic constipation. J. Bodyw. Mov. Ther. 2011;15:436–445. doi: 10.1016/j.jbmt.2010.07.007.) • Pathophysiology- Complex & Multifactorial • Common in patients with positive family history Genetics is not known • Identical twins have 6 folds possibility than non identical twins.
  • 4. Normal frequency of bowel movement
  • 5. Chronic Constipation Definition Rome 4 Criteria Ref: Lacy B.E., Mearin F., Chang L., Chey W.D., Lembo A.J., Simren M., Spiller R. Bowel disorders. Gastroenterology. 2016;150:1393–1407.e5. doi: 10.1053/j.gastro.2016.02.031.
  • 6. In Infants Up to 4 Years Must include 1 month of at least 2 of the following • 2 or fewer defecations per week • History of excessive stool retention • History of painful or hard bowel movements • History of large-diameter stools • Presence of a large fecal mass in the rectum In toilet-trained children: • At least 1 episode/week of incontinence after the acquisition of toileting skills • History of large-diameter stools that may obstruct the toilet
  • 7. For Children Greater than 4 Years Must include 1 month of at least 2 of the following • 2 or fewer defecations in the toilet per week • At least 1 episode of fecal incontinence per week • History of retentive posturing or excessive volitional stool retention • History of painful or hard bowel movements • Presence of a large fecal mass in the rectum • History of large diameter stools that can obstruct the toilet
  • 8. Natural course Large dilated rectum, Palpable abdominal fecolomas, With overflow soiling often without sensation Soiling
  • 9. ‘Soiling’ • Often referred to as ‘constipation with overflow’ • Inappropriate passage of stool in underwear associated with chronic constipation • Faeces are often loose and ‘smelly’ • Involuntary action over which child has no control
  • 10. Classification Etiology : Primary & secondary • Primary constipation -constipation predominant irritable bowel syndrome (IBS-C), functional constipation, slow transit constipation (myopathy, neuropathy, and functional defecation disorders) • Secondary constipation -metabolic disorders (e.g., hypercalcemia), medications (e.g., calcium channel blockers or opiates), primary colonic disorders (e.g. HD,ARM,) and neurologic disorders(Spina bifida) Daniali M., Nikfar S., Abdollahi M. An overview of interventions for constipation in adults. Expert Rev. Gastroenterol. Hepatol. 2020;14:721–732. doi: 10.1080/17474124.2020.1781617.
  • 11. Colonic transit- 3 sub groups Normal colonic transit- suffer from functional constipation- Commonest Type Rectal evacuation disorders- Dyssynergic defecation Mechanisms: paradoxical anal contraction, impaired rectal contraction and inadequate anal relaxation. Slow colonic constipation- dysfunctional retrograde colonic propulsion
  • 13. Functional constipation- Etiology • Inappropriate toilet training • ‘Holding on’ - often initiated by passage of large / painful stool • Toilet phobias / fears • Child sexual abuse • Anal fissure
  • 14. Functional constipation- Etiology • Delay in passage of normal stool • Avoidance of response to nature call • Inconvenient / uncomfortable places • Vicious cycle of retention development.
  • 15. Functional constipation- Etiology • Insufficient fiber or fluid intake • Cow’s milk allergies • Lack of exercise • Obesity • Dysbiosis of gut microbiota (Decreased number of Actinobacteria in fecal samples and increased level of Bacteroides in their mucosal samples)
  • 16. Organic Constipation- Etiology • Hirschsprung's disease, • Anorectal malformations • Spina bifida- MMC, OSB • Trauma to spinal cord • Intestinal Tumors, Intestinal Pseudo Obstruction
  • 17. Organic Constipation- Etiology • Endocrine, Metabolic and GI disorders -Hypothyroid -Hypokalemia -Hypercalcemia -Cystic Fibrosis, Coeliac disease -DM -DI
  • 18. Organic Constipation- Etiology • Drugs -phenobarbital, antacids, anticholinergics -antidepressants, opiates • OTHER • -Botulism • -lead ingestion
  • 19. Constipation – Risk Factors • Insufficient fiber or fluid intake • lack of exercise • Positive family history • dysbiosis of gut microbiota Ref: Iacono G., Scalici C., Iacono S. Chronic Costipation as a Symptom of Food Allergy. Austin J. Allergy. 2016;3:1024. Ref: Ohkusa T., Koido S., Nishikawa Y., Sato N. Gut microbiota and chronic constipation: A review and update. Front. Med. 2019;6:19. doi: 10.3389/fmed.2019.00019.
  • 20. Constipation – Risk Factors Environmental issues • Unhygienic School toilets! • Toilets - cold/dark • Toilets - dirty • Uncomfortable toilet seats • Lack of privacy • Lack of toilet paper • Inaccessible lavatory
  • 21. Constipation – Risk Factors Psychological factors • Fear • Precipitating family stress • Learned behaviour • Anxiety, • Trauma • Depression • Attention deficit disorder • Autism Ref: S., Devanarayana N.M., Perera B.J.C., Benninga M.A. Childhood constipation as an emerging public health problem. World J. Gastroenterol. 2016;22:6864–6875. doi: 10.3748/wjg.v22.i30.6864.
  • 22. Recent- Mechanism Possible mechanisms • Decrease in the number of Cajal cells • Disruptions in the serotonin level. Ref: Camilleri M., Brandler J. Refractory Constipation: How to Evaluate and Treat. Gastroenterol. Clin. N. Am. 2020;49:623–642. doi: 10.1016/j.gtc.2020.05.002.
  • 23. Evaluation • History. • Physical examination • Radio imaging.
  • 24. History- Constipation ‘ Red flag’ symptoms • Delayed Passage of meconium > 24 hrs • Abdominal distension in failure to thrive patients • Infrequent small or ribbon stools • Constant stool leaking along with urinary leaking (Bowel bladder dysfunction) • Failed management with appropriate therapy
  • 25. General health profile Check for: • Daytime urinary problems • Nocturnal enuresis • Appetite / approximate fibre intake • Fluid intake • Any medical problems • Any current medication
  • 26. Bowel profile • Description of stools - frequency - consistency - size - any pain /discomfort/blood/mucus • Use of toilet / potty • Any previous treatments /interventions
  • 27. Toilet training profile • Age-toilet training commenced • Age for bladder control • Age for bowel control • Any significant changes / problems / events occurring at this time
  • 28. Physical examination • Growth of the child • Abdominal Distention • Fecal mass felt on abdominal examination. • DRE: for loaded rectum • Fecal soiling. • Ano-genital index
  • 29. • Anal fissure / perianal excoriation • Signs of trauma (abuse). • Signs of spinal defects • Neurological assessment of L.L. and anal canal. • Occult blood in stool • Absence of anal wink • Decreased lower extremity tone & strength
  • 30. Investigations • Plain abdominal X RAY. • Lumbosacral X RAY / MRI • Ba. Enema • Anorectal manometry. • Rectal biopsy. • Anal sphincter EMG. • Defecography. • Colorectal transit study.
  • 31. • Free T4, T4 & TSH • Na, K levels • Serum Calcium • CBC
  • 33. X ray abdomen- Fecal loading
  • 37. Colorectal transit study Delayed colonic transit time. An even distribution of the markers throughout the colon, is characteristic for slow-transit constipation.
  • 38. Constipation Management • Education • Evacuation • Maintenance
  • 39. Constipation management- Education Demystification – child and family need to be aware of:  Normal variation in bowel habits  Protracted course of treatment  Relapses are common  Long term laxatives often required -only to be stopped on advice  Symptoms may get worse initially
  • 40. Education • Demystification with written information • Structured toileting programme • Consistent scheduled toileting • Positive reinforcement • Diet & fluid adjustment • Promote Sports activity
  • 41. Dietary Intervention • Balanced diet-whole grains, fruits, vegetables • Adequate water intake Fluid- 85 to 90 ml/kg/day • High fiber diet or Supplements: Age in years + 5gm • Avoid foods that constipate- white rice, ripe bananas, tea, Coffee, Chocolate, Junk Foods, Biscuits, Milk & Milk products • Don’t force diet on child- best success when child feels in control
  • 42. Behavioral modification: • Regular toilet habit • Keep diary and record of toilet • Motivation (avoid negative comments) • Modify parental behavior- no rushing in the morning to leave for school--allow for adequate toileting time • No punishments or ridicule for constipation or soiling • Identify psycho-social stressors
  • 43. Evacuation • Manual disimpaction under Short GA • Distal Colonic Washouts- Enemas(Sodium Phosphate and Glycerine suppositories) • Proximal Washouts- Oral lavage with polyethylene glycol solutions-recommend 1 to 1.5 g/kg/day
  • 44. Disimpaction Polyethylene glycol: Movicol / Pegalup / Relux: • 2-4years: 2-8 sachets, • 5-11 years: 4-12 sachets – to be started with minimum number of sachets for age and increase every other day until evacuation complete (usually within 7 days). Supervised PC enemas
  • 45. Maintenance therapy Aim to prevent relapse • On going advice and support • Continue with diet/fluid advice • Long term laxative therapy • Consider cautious reduction 6 monthly • Behaviour modification
  • 46. • Use adequate doses of laxatives to pass stool once or twice every day • May need to use a combination of stool softener, bulking agent and bowel stimulant (lactulose/PEG, Fibre and senna) • Will need at least 6 months treatment and often much longer to learn/re-learn bowel habit
  • 47. Laxative Dosage • Lactulose: <1 year:2.5ml bd; 1-5 years: 5ml bd; 5-10 years: 10ml bd • PEG( Macrogol): 1gm/kg/day 2-6 years:1-4 sachets, 7-11 years:2-4 sachets per day (titrate dose as necessary) • Senna (syrup): 2-6 years: 2.5 – 5ml in morning, over 6 years: 5-10 ml • Mineral oil (Liquid paraffin oil); 1-3 ml/kg/day • Docusate (oral solution): 6 months to 2 years 12.5 mg tds; 2-12 years 12.5 – 25 mg tds;
  • 48. Surgical Treatment Newer Evaluation modalities: • Dynamic magnetic resonance proctography Dynamic anal endosonography Scintigraphic proctography Will Diagnose: Anatomical defects: Rectocoele, Internal prolapse, Perineal descent, and atypical herniations including Enterocoele and Levator ani defects Functional defect: Anismus ( Puborectalis paradox) Rentsch M, Paetzel C, Lenhart M, et al. Dynamic magnetic resonance imaging defecography. Dis Colon Rectum. 2001;44:999–1007
  • 49. Surgical Treatment: • Anorectal Myectomy for anal sphincter achalasia, SSHD. • MACE: Malone antegrade continent enema Antegrade colonic irrigation using an appendicostomy- for Spina Bifida & ARM • Idiopathic slow-transit constipation: 1. Temporary defunctioning colostomy. 2. Colectomy and ileo-rectal or ileo-sigmoid anastomosis • Anismus: 1. Biofeedback- modify higher center control of defecation 2. Pharmacological puborectalis paralysis using botulinum toxin
  • 50. Constipation and Magarectum / Magabowel • Intractable constipation in childhood • Involves rectum ,sigmoid and more proximal colon • Etiology: -50% idiopathic (intact RAIR & normal ganglia on full-thickness biopsy.), Chagas disease , chronic intestinal pseudo-obstruction, ultrashort–segment Hirschsprung’s disease. • Pathophysiology of these idiopathic cases is poorly understood • Treatment: laxatives and enemas for at least 6 months If fails: • colectomy and ileorectal/ileosigmoid anastomosis, • proctectomy and coloanal anastomosis, • pull-through procedures- Duhamel operation, • anal myomectomy and more recently • restorative proctocolectomy.
  • 51. Long-Term Outcome of Functional Childhood Constipation Childhood constipation appears to be a predictor of Irritable Bowel Syndrome in adulthood.