Tanya is a 4-year-old girl presenting with a 2-year history of constipation, opening her bowels every 5 days and straining with intermittent abdominal pain and occasional soiling. A hard stool mass is palpable on examination. Constipation can be caused by organic issues like strictures or functional issues like withholding behavior after painful bowel movements. Treatment involves softening the stool with laxatives, relieving impaction, patient education on diet and toilet habits, and behavioral management.

1. Case in pediatric
gastroenterology -
constipation

2. History
Tanya is a 4-year-old girl who presents to outpatients with a 2-year history of
constipation.
She opens her bowels about once every 5 days and strains.
She soils her knickers on most days.
She has intermittent abdominal pain, which is relieved by opening her bowels.
Recently, there has been fresh blood on the toilet tissue. Lactulose has been used,
with little success.
Her mother states that she did not have a dirty nappy until 40 hours of age. She has
recently had a urine infection diagnosed by her GP. The illness was mild and
responded well to antibiotics. She was delivered by emergency Caesarean section
because of fetal distress and meconium staining

3. PE
A faecal mass is palpable in the left iliac fossa.
The anus appears normal.
Rectal examination – hard stool palpated.
The back is normal.
Blood pressure is 101/62 mmHg. Weight is on the 50th
centile and height is on the 25th centile.
There are no other signs.

4. Importance of bowel movement
control
• Social
• Hygiene
• constipation

5. Definition
• Stool frequency
• Stool consistency
• Significant enough to cause distress
• “normal”-depend on age

6. Breast fed baby
• Frequency- 10 /day – once every 10 days
• Consistency-soft , yellow (“cottage” like )
• Need to be sure – no vomiting
abdomen is not distended
good weight gain

7. Stooling
• Depend on- bowel peristalsis
anal reaction to stool mass
• Internal sphincter- reflexogenic relaxation
• External sphincter- self controlled
relaxation

8. Organic causes
• Stricture- anal stenosis, post surgery
• Muscular –prune belly , gastroschisis
• Neurogenic – hirschprung ,pseudo-
obstruction
• Medication- narcotic, anticholinergic
• Metabolic-hypothyroidism , hypokalemia
, hypercalcemia

9. Other diseases
* Celiac disease
* Cow milk protein allergy
* Cystic fibrosis (DIOS/ meconium ileus
equivalent)
* IBD (stricture)

10. Functional constipation
• Start after neonatal period
• Acute episode precedes the chronic course
• The acute episode can be-change of diet
Toilet training period
acute gastro-enteritis
inconvenient stooling
(dirty toilet, trip)
• Painful passage of bowel movements causes pain-
withholding

12. Clinical presentation
• Avoid stooling
• Caregiver may misinterpret behavior as straining
• Abdominal pain
• Large diameter stool
• Rectal bleeding
• Encopresis
• Recurrent UTI

13. History
• When constipation started
• When did the child passed meconium
• Frequency of bowel movement
• Consistency of stool
• Blood on toilet paper
• Behavior before defecation
• abdominal pain and connection to meals and
defecation
• Diet / water
• Toilet training

15. Physical examination
• Large volume of stool palpated at descending colon
• Underwear soiling (mistaken as diarrhea)
• Rectal examination-dilated rectum filled with hard
stool , anal fissure
• Spinal dimple/hair tuft over spine
• Cremasteric reflex
• Lower legs reflexes

16. evaluation
• In refractory patient
• Blood tests- thyroid function , calcium level, celiac serology
• Rectal biopsy
• Motility tests-colonic transient time , anal manometry
• MRI of spine
• Contrast enema

17. Treatment
• Softening of stool-polyethylene glycol
lactulose
mineral oil
• Relief of impaction-enema
• Patient education-balanced diet
regular post prandial toilet sitting
reward the child for adherence
avoid power struggles
• Behavioral management
• Surgery