This document discusses chronic constipation in children. It presents the case of a 3 year old boy with hard stool, painful defecation and infrequent bowel movements. On examination, fecoliths were palpable and soiling was present. The document outlines an approach to evaluating and managing functional constipation in children, including disimpaction, diet modification, toilet training and maintenance laxative therapy. It also discusses red flags requiring further investigation to rule out organic causes and presents a second case of a child with Hirschsprung's disease.

1. Chronic constipation
in children
Anshu Srivastava
Department of Pediatric Gastroenterology,
SGPGIMS, Lucknow, India

2. 2 yr 2 ½ yr 3 yr
SGPGI
Constipation
3 yr boy
Stool freq 1/day Once in 7-8 days
• Stool: hard, large size
• Painful defecation
• Withholding manoeuvre
• No blood with stool
Milk intake: 1 liter/ day
• No h/o enterocolitis: abdominal distension,
fever, loose stools
• No h/o drug intake
• Passed stool on day 1 of life
• Normal growth
• Developmentally normal
Lactulose Enemas
Modified diet
Soiling

3. Anthropometry
Height : 87.5cm
Weight : 12 kg
OFC : 47cm
Age
Appropriate
• No pallor, edema

4. Examination
• Per abdomen: Not distended
Fecoliths palpable in left iliac fossa
• Inspection of anal area:
Normal position
No perianal tags
Anal wink present. No anal fissure
Soiling of undergarments present
• Per rectal: Normal anal sphincter tone
Hard stool present in the rectum
No gush of air after removing the finger
No blood

5. Examination
• CVS and RS: NAD
• CNS: Normal muscle tone
Power: 4/5
DTRs Normal
Planters reflexes- Flexor response
Gait: Normal
Sensations: Touch and pain present
Good urinary stream
• Back and spine: Normal

6. Functional
Constipation
with soiling
Onset
After 1 yr of
age
Fecoliths,
Withholding
maneuver
Normal
Growth
No
Enterocolitis
Possibility

7. Clarity of terminology
Fecal incontinence
Organic Functional
Constipation
associated
Fecal impaction
Large
fecal mass
Rectum
Abdomen

8. Red flags on history
• Age of onset <1y (first few weeks)
• Delayed passage of meconium (>48hr)
• Failure to thrive
• Absence of withholding
• Absence of soiling
• Bladder dysfunction
• Extra-intestinal symptoms
• No response to conventional therapy ?
PCNA 2002;49:27-51

9. Red flags on examination
• FTT
• Abdominal distension
• Pilonidal sinus
• Midline pigmentary abnormalities
• Patulous anus, anteriorly placed anus
• Empty rectum
• Gush of liquid stool & air from rectum after
finger withdrawal
• Absent anal wink, cremastric reflex
• Lower limb weakness

10. Investigations
Bil Conj Protein Albumin AST ALT SAP
Jan 2010 1.3 0.2 7.8 4.2 54 42 134
Hb TLC DLC Platelets PF
Jan 2010 11.1 11400 60/36/4 323000 NCNC
Thyroid function tests (from elsewhere) – Normal
Barium enema (done elsewhere)- Megacolon
Not s/o Hirschsprung’s disease

11. Algorithm for evaluation
Constipation
Red flags on evaluation
Functional constipation
Assess fecal impaction
Disimpact
Investigate
and manage
No
No Yes
yes
Dietary advise
Toilet training
Maintenance
Laxative therapy
Follow up
- response and compliance
- dose titration
- recurrence of impaction

12. • Clear Fecal Retention
• Prevent Future Retention
• Promote Regular Bowel Habit
Management-treatment plan

13. Management contd….
• Clearance of fecal retention: Dis-impaction of stools
Admitted
Polyethylene glycol (PEG) with electrolytes:
20ml/kg/hr – till disimpaction achieved
End point of disimpaction: Passage of clear fluid of
nearly same color and consistency as being used for
disimpaction

14. Management contd….
• Counseling of parents:
Acquired disorder and curable
• Toilet training:
• Diet chart: high fiber diet
• Maintenance: Laxative
Polyethylene glycol
(Dose: 1g/kg/day) ¾ sachet (12 g)/ day

15. Dietary advise
• Preferred food √
– Whole grains
– Whole pulses/beans
– Green leafy vegetables,
beans
– Fruits-guava,
pomengranate, dates,
amla, apple with peel
• Avoid X
– Refined wheat flour
– Arhar, dhuli moong
– Predominant milk diet
– Banana, papaya, mango
Ideal fiber intake- age in years + 5 g
Healthy nutritious diet with adequate fluid intake
Some benefit that fibre is better than placebo
Ped 2011;128:753

16. Diet chart: High Fiber Diet
• मुख्यतह आहारमें शामील करे-
छिलके सहीत दाल
हरी पत्तेदार सब्जियाां, सेम, परवल , मटर, छिलके सहीत आलू I
सलाद (अच्िी तरह साफ़ करके )
अांकु रीत मूांग / चना
फल (सांभवतः छिल्के सहहत ) अच्िी तरह साफ़ करके खाए I
अमरुद, आवला, सीताफल, चीकू , खिूर, अांगूर तथा अनार का
प्रयोग करे I

17. Drug Dosage Side effects
Bisacodyl <2y- 5mg supp
≥2 y- 10 mg suppository
>6y-1-2 oral tablets (5 mg)
Abdo pain,
diarrhea.
Senna 2-4y:3.75-15mg/d
4-6y: 3.75-30mg/d
6-18y: 7.5-30mg/day
Abdo pain
Skin rash and fixed
drug eruption rare
Sodium picosulfate <4 y: 2.5–10 mg once a day
4–18 years: 2.5–20 mg OD
Abdominal cramps
and diarrhea
Stimulant laxatives
Bisacodyl, senna, sodium picosulphate
As rescue therapy for intermittent use only
No drug trials available in children*
Coch Rev 2001;issue3 CD 002040
Cisapride and probiotics not recommended

18. Stool
frequency
Jan 10 July 10 Jan 11 July 11 Jan 12
Diet and toilet training
Fecal soiling
Withholding
maneuver
Daily 1-2 soft stool
PEG
¾ Sachet
(1 g/kg/ day) ½ Sachet
(0.75g/kg /day) Alternate day
Stopped
1 year
Titration of dose as per response
No soiling and with holding maneuver

19. Treatment in infant
Rule out congenital mega colon
Transition to dietary supplementation: constipation
 Increased fluid intake, sorbitol containing juices (apple, pear,
prune)
 Lactulose and PEG are safe
 Glycerin suppositories are useful
 Avoid enemas
 Contraindicated:
Stimulant laxatives
Mineral oil
JPGN 2004; 39: 197-99, JPGN 2004; 39: 536-39

20. Algorithm for follow-up
Maintenance treatment effective
Assess for
• Re-impaction
• Check compliance/ diet/ stressor
Treatment effective
Organic etiology?
Specialized tests
Gradual weaning
Relapse
Stop medication
Follow up
No
No
No
Yes
Yes
yes
Change medications

21. Investigations
All children with constipation do not need investigations
Investigations required in :
Patients with red flags on history or examination
at first evaluation
Patients with poor response/ no response despite
therapy
-After ensuring dietary and medication compliance
- After excluding impaction

22. Organic causes of constipation
Intestinal nerve/muscle disorder: Hirschsprung ds,
Intestinal neuronal dysplasia, pseudo-obstruction, spinal
cord (teethered cord, myelomeningocoele)
Anorectal: anteriorly placed anus, anal stenosis, pelvic
mass (sacral teratoma)
Endocrine/ metabolic: hypothyroid, diabetes insipidus,
diabetes mellitus, hyper calcemia, cystic fibrosis, celiac
disease
Developmental: mental retardation, autism, child abuse
Drugs: opiates, anticholinergic, pheno barbitone,
vincristine, lead

23. SGPGI data

24. 8 yr boy
• Abdominal distention from early new born period
• Constipation
• Failure to thrive
• H/O delayed passage of meconium
• No h/o enterocolitis or vomiting
• Dietary history- weaning at 8 months, normal diet
thereafter
• Development – normal
• No significant family history
Case 2

25. Examination
General examination
• Mild pallor, clubbing
• Wt:16.6 kg (<5th centile), Ht:114 cm (<5th centile)
Abdomen
• Visible peristalsis noted in right iliac fossa
• No organomegaly
• PR- soft stools +, no gush of stools
Other systems –NADClinical possibilities??
Hirschsprung’s disease
Intestinal Pseudo obstruction

26. Barium Enema
X-ray Abdomen
Erect
Barium enema
X ray abdomen and barium enema

27. Barium enema in HD
Precautions
– Don’t use enemas before - may distort a low
transition zone.
– The catheter just inside anus without
inflating balloon, to avoid distortion of a low
transition zone
- Don’t over distend
Radiographs
– Recto/sigmoid ratio, normal >1
– Transition zone

28. Anorectal manometry
No rectoanal inhibitory reflex
Diagnosis: s/o Hirschsprung’s disease
Resting RAIR

29. Normal RAIR

30. Diagnosis and follow up
Patient underwent laparotomy
• Transition zone in sigmoid colon
• Frozen section; absence of ganglion
cells
• Duhamel’s procedure done
Dilated
proximal
ganglionic
bowel
Collapsed
distal
aganglionic
colon
Clinical picture and 3 main tests
• Rectal suction biopsy
• Contrast enema
• Anorectal manometry
Gold standard: Full thickness biopsy showing absence of ganglion and
increased acetyl cholinesterase activity

31. Differentiating HD and Functional
constipation

32. Colonic transit study
• Total and segmental colonic
transit time (CTT) by radio-
opaque markers or
scintigraphy.
• Subtypes:
-normal colonic transit
-slow transit constipation
-outlet obstruction
J Pediatr Gastro Nutr 2002; 35: 31-8

33. Colonic manometry
Patterns:
Normal-Presence of normal high amplitude
peristaltic contractions (HAPC) and increased
contractions after a meal (gastro-colonic
reflux)1
Myopathy- Absent/weak contractions in
absence of colonic dilatation
Neuropathy- Absent gastro-colonic response,
absent or abnormal HAPC
1J Pediatr 1995; 127: 593-6

34. Colonic manometry

35. Management
• Targeted towards organic etiology
-surgery in Hirschsprung’s disease
-gluten free diet in celiac disease
-dietary alterations in food allergy
-botulinum toxin in anal achalasia
• ACE (Antegrade continence enema ) procedure
• Colectomy (select cases)

36. Conclusions
• Constipation is a common problem
• Majority of childhood constipation is functional
• Detailed history, examination and counseling is crucial
• Requires prolonged tailored therapy and follow-up, no
miracles to be expected
• Presence of red flags and non-response despite
adequate treatment and good compliance suggests
need for investigation