4. • Time of onset of constipation?
• How hard and how often?
• Is it painful? Any blood in stools?
• In what posture does he pass stool?
• What is his diet like?
•
Constipation:5 IMPORTANT QUESTIONS
5. 4 year old child : Abdominal pain - 10 mths & bed wetting 6mths
vomits feeds + Leaky stools / fecal soiling
Pain periumblical and left lower quadrant , colicky ,
irregular bowel habits – timing , rhythm and straining –
defecation phobia in view of pain due to hard pellets
O/E faecal lumps per abd , faecal soiling , circumcised 2yrs ago
On antacids , PPI , regularly antispasmodics , by many drs - no relief
Investigations: CBC, x-ray chest, Mx, stools(EH cyst),
urine routine & C & S – Normal USG; Ba Meal – Normal
Surgical opinion : Nil surgical What next?
.
Case scenario
6. PR : anal crack , dry pellets needing disimpaction - rewarding
G E opinion -
Faulty diet Ch hab constipation
Stool history & with impaction +
Defecation habits voiding dysfunction
Abdominal Scyballa
PR - pasty pellets
soiling +
-
7. Causes of constipation
NEWBORN & LESS THAN 3 MTHS OF AGE
• Meconium plug syndrome – cystic fibrosis
• Anorectal malformations
• Hirschsprung’s disease
• Hypothyroidism
10. Beware …….red flag signs
• Unintentional weight loss
• Anemia
• Rectal bleeding
• Family H/o colon cancer
• Change in stool caliber
• Pain
11. Examine for fissure ,soiling , scars , fistulae & haemorrhoids
Look for perineal descent with patient bearing down to identify
excessive descent
( Below the plane of ischial tuberosity or > 3.5 cm ) indicates
laxity of perineum ( defecation disorder )
PR for fecal impaction, stricture, mass, sphincter toneat rest, &
during voluntary contraction
Test perineal sensation in severe constipation (spinal cord
pathology)
12. INVESTIGATIONS
• Good history & physical examination
• PR is essential
• <5%- organic-tests rarely needed
• X-ray abdomen in loaded colon
• Barium enema – Dilatation from Anal verge
in habit constipation.
Transition Zone in
Hirschsprung disease
Rarely to look for strictures
13. Management: Recommendations for Infants
A Medical Position Statement of NASPGAN
Disimpaction:
By glycerine suppositories
Enemas to be avoided
Maintenance:
Juice containing sorbitol(prune,pear,apple)
Lactulose or sorbitol as laxative
Mineral oil & stimulant laxative: not recommended
J Ped Gastro Nutr 1999;29:612-626
14. Management: recommendations for children
• Disimpaction: Either by oral or rectal medication,
including enemas
• Maintenance:
Diet: A balanced diet,containing whole grains,
fruits, vegetables
Laxative: Lactulose,sorbitol,magnesium hydroxide,
mineral oil
Behavioral therapy: Toilet training ( 5 min after meal )
Rescue therapy: Short course of stimulant laxative
Intractable constipation: Bio-feedback therapy
J Ped Gastro Nutr 1999;29:612-626
16. Drug Dosage Side effects
Lactulose 1-3ml/kg/day, 1-2 doses.
Adjust dosage to
response seen
Abdominal cramps,
flatulance
Milk of
magnesia
1-3ml/kg/day,1-2 doses
Adjust dose to
response seen
Over dose-
hypermagnesemia,
hypophosphatemia,
hypocalcemia
Sorbitol 1-3ml/kg/day,1-2 doses Abdominal cramps,
flatulance
Mineral oil
(Liquid
Paraffin)
Disimpaction 15-
30ml/year of age.(max
240ml) Maintenance-
1-3 ml/kg/day
Lipoid pneumonia
LAXATIVES
17. Drug Dosage Side effects
PEG (Poly
Ethylene
Glycol)
Disimpaction-25ml/kg/hour
Maintenance-5-10ml/kg/day
or 0.5-1g/kg/day
Nausea, bloating, cramps,
vomiting, anal irritation.
Senna syrup: 8.8 g sennoside/ 5 mL 2–5
years: 2.5–7.5 mL/day in two
divided dosages. 6–12
years 5–15 mL/day in two
divided dosages (Tablets and
granules available)
Idiosyncratic hepatitis,
melanosis coli, hypertrophic
osteoarthropathy, analgesic
nephropathy, abdominal
cramping. Melanosis coli
improves after medication
stopped
Bisacodyl 5 mg tablets, 1–3 tablets/dosage
1–2 times daily.
10 mg suppositories, 0.5–1
suppository, 1–2 times daily
Abdominal cramping, diarrhea,
hypokalemia
LAXATIVES Contd.
18. RAP: how to handle a child with organic pain ?
DR. HEMA VIJAYALUXMI
19. Term CAP is current & RAP is out- dated
“ Pain details pays dividends for diagnosis ”
At least 3 episodes over 3mths at onset with clinical
variation - time frame of 1-2 months - affecting daily activity
Site , extent & radiation
Type (colicky/ gnawing /dull ache/ vague & nondescriptive)
Severity: sleep awakening , disturbed daily activity & special
postures any during pain for temporary relief
Presence of “red flags of organic disorders ” or psychic triggers ?
Constant / intermittent - Intervals-asymptomatic / symptomatic?
Relation to food, defecation , school examn ,working/holidays?
Milieux & critical stressful events any with headaches ?
What relieves & aggravates ?
20. Location & presentaton of abd.pain : Diagnostic clue
*Organic ( any age ) : Well localized , colicky ,at specific sites &
radiating ( +/-) & +ve red flag . Positive physical signs
Specific investigations diagnostic support
__________________________________________________________
* Psychological (> 5yrs) : Vague , inconsistent , school going child
Physical examination NAD –Fake pain
Day time pain , +VE Psychic triggers
Investigations not contributory
__________________________________________________________
* FAP (> 5 yrs of age ) : Centri-abdominal /epigastric , paroxysmal
nonradiating pain , unrelated to food or physical activity , varying
severity & affecting daily activity = FAP (> 5 yrs of age )
Physical exam NAD but “ Real pain without any identifiable cause
All investigations not contributory
21. Location & type of abd. pain : Diagnostic clinical clue
• Ch constipation : Periumbilical / LLQ abd colic /pricking / defaecation issues
• Cholecystitis : RUQ pain + Murphy’s sign +ve
• Ch pancreatitis : Epigastric pain boring to mid back, recurrent & tenderness
• Small bowel obstruction(worms , Stricture or adhesion ) : Centri abdominal colic ,
distension & VIP
• Functional dyspepsia / GERD / PUD / H pylori or NSAID gastritis: Food related
epigastric pain /gnawing ,retching , regurgitation, early satiety .
•
22. Location & type of abd. pain : Diagnostic clue
Abd wall pain (parietal pain) : Carnett sign +ve
Cystitis & Voiding dysfunction : Hypogastric ache &
tenderness
Ch appendicitis , Ileo-caecal TB , Crohn’s disease :
RLQ intermittent colic with constant finger point
tenderness
23. Red flag signs
(Specific history , +ve physical
sign & lab spport )
History Physical examination
Localized pain ,often colicky
away from umbilicus
Consistent RUQ/ RLQ pain &
tenderness
Weight loss Growth retardation (deceleration)
Pain awakens the sleep Abnormal postures& finger points
Copious biliuos vomit / GI bleed Pallor & Stool occult blood +ve
Unexplained fever , arthralgia ,
Rash , urinary symptoms , ch. severe
diarrhoea, lethargy
Organomegaly
Lymphadenopathy
Abd. distension ,obstipation Abd. scars with visible bowel loops
Hernia of abdominal wall
Family h/o IBD / PUD H/O Abd surgery - scars with visible
bowel loops Hernia of abdominal wall
24.
25. Faecal load –rectosigmoid Faecolith )+ve in 30% appendicitis
Renal calculus ileocaecal subacute obstruction Ureteric calculus
Pancreatic calculi
Don’t forget x-ray abdomen
More useful than USG abd.
26. Diagnosis arrived by ultrasonogram
Hepatobiliary: Gallstones / Choledochal cyst
Pancreatic: Ch.pancreatitis / pancreatic stones
Urinary Tract: Stones / hydronephrosis
GI tract : Duplication cysts of bowel
Pelvic : PCOD
Day to day burning issue ? * Silent GB stones
* Mesenteric adenitis
* Appendicitis
27. CT diagnosis of appendicitis
1. Incomplete filling with contrast material
or air exceeded 6mmin cross sectional diameter
2) Appendiculolith or adjacent extraluminal air,
complex fluid collection
3) Mass ( USG detects)
Nonvisualisation of appendix in many normal cases
AJR;175: 2008
Asymptomatic GB stones :Invariably resolve in due course
Reassure & review with 6monthly USG abdomen
Prophylactic lap-chole in haemolytic states
Lap- chole for typical biliary symptoms
UDCA – medical resolution not beneficial
Ujjal Poddar , Indian Pediatr 2010;47 : 945 -953
_______________________________________________________
Significance of mesenteric adenitis in USG / CT( incidental )
Size : short axis diameter >10mm ( N = < 5mm – 10mm )
Shape : rounded mostly
Number : clustering of > 3 nodes
Site : central / peripheral
Echogenicity:altered( caseation , abscess or calcification)
Cl correlation - if no red flags = unrelated to CAP
( Often due to subclinical rec infections / bowel stasis
Reassure & review with 6 monthly USG / CT(resolve mostly)
AJR 2002; vol 178 (4) & aium July 2013 ; 32 (7)
_________________________________________________
30. FAP : Characteristic presentation
3 or more episodes over 3 mths
Symptom free intervals between pain episodes not mandatory
Daily activity affected. Not sleep awakening necssarily
No cause found. Unrelated to meals & daefecation
Real pain, variable intensity , clustering / paroxysmal (3 > mts)
gradual in onset , nature & site not often clear, centri abdominal
mid epigastric . Pt keeps entire hand over the area
( cf : away from umbilicus in organic & inconsistent in psychic )
Nausea , vomit ,head ache , pallor , fatigue may be +
( Bilious vomit with red flags+ in organic pain )
Clinical examination NAD
Investigations not supportive but rules out
organic causes when suspected with red flags ?
31. Role of lab tests in FAP-how far to investigate ?
* Unnecessary if the history & physical examn. = diagnosis of FAP
* Investigations done in cases of “ red flag signs ” only
* Medical tests reassure the pt & family & at times the physician
if there is significant functional disability & poor quality of life
* Basic screening tests : CBC , urine & stool routine , stool occult blood ,CRP ,basic
chemistry panel(blood sugar, urea, creatinine)
urine C & S,
Food allergy tests : Celiac serology & CMPA specific IgE Ab
Elevated stool caloprotectin = Inflammatory pathology
Empiric Symptomatic therapy: H2RA,PPI, Prokinetics X 2 wks.
Role of Plain x-ray abdomen & Ba study
USG abdomen to rule out organic cause
CT/ MRI abdomen
OGD / Esophageal ph Beware of any burning issues USG abd reports?
32. Functional Dyspepsia: Investigations
OGD scopy when empiric treatment fails or Red flag
symptoms present
24 hr ph study of Oesophagus for GERD
when medical treatment fails & on request by distressed
parents to the extent of surgery or GERD with EE issues
*CECT abd can pick up Crohn’s, koch’s abd,microliths, nodes
33. Role of UGI scopy
only
when empiric treatment fails or red flag s/s +ve
In children with pain epigastrium - UGI scopy helps to
detect esophagitis, gastritis and duodenal ulcer.
Little evidence to suggest that use of USG, UGI scopy
or esophageal pH monitoring will yield a clue of
organic disease in the absence of alarm symptoms
PEDIATRICS 2005; 115: 370-81
34. Counselling parents …
• Acknowledge: Your child feels pain
• Reassure: Your child has no serious
organic disease. Liken it to a headache
• Counsel: Your child has a very
sensitive gut.The gut’s little brain feels
pain much more than others
• We have medicines which will make
him feel better
35. CAP : Real pain No positive phy findings , no identifiable
cause , lab test, USG,CT etc.& endoscopy normal – lap
appendicectomy status- parental concern & puzzled
doctor - how do you explain the pain ?
Possible pathogenesis of FAP : Gut-brain interaction
↓
Visceral hypreralgesia
↑
1. Abnormal bowel activity (IBS-D , IBS-C , IBS- Mixed)
2. Physiological stimuli(meal,gut distension,hormonal)
3.Noxious stressful stimuli ( inflammatory process)
4.Psychological stressful stimuli (parental separation,anxiety )
36. Case Snippet : When to suspect abdominal migraine ?
(In the preceding 12 mths , 2 or more times)
1. When episodes of paroxysmal acute & intense centriabd pain -
1-2 hrs associated with nausea ,vomiting ,anorexia , uni /bi-
temporal throbing headaches , photophobia & pallor (any two) .
2. Complete recovery between episodes
3. Strong family h/o migraine=diagnostic credibility (not always +ve)
4. Pain interferes with normal activity
5. Clinical examn. NAD
CECT , MRI BRAIN not supportive
38. Symptom overlap – a challenge
Child with chronic pancreatitis may develop a
psychological overlay due to chronic depression
Child with functional abdominal pain may
develop appendicitis
Current concept : In some children CAP pain
may be a combination of functional abdominal
pain with somatic/ Psychic triggering elements
39. Role of drugs in FAP
Nausea, satiety & bloating = gastroparesis Erythro / prokinetics
Postprandial epigastric pain,
Belching , wt loss = gastric hypersensitivity Amitryptaline
Functional dyspepsia = functional dysmotility : clonidine
Prokinetics,LSM,
(eg. GOR , NUD & for pain -Sumatriptan ,Buspirone
Abd distension = hypersensitivity to acids / lipids Amitryptaline
Alosetron , clonidine
Organic painPUD like = Hpylori infection 2 antibiotics &1PPIx2wks
DR.Nirmala
40. Practitioner’s learning points ? DR.VSS
• Strip clothings during phy examn not to miss rashes , hernia etc.
• Avoid empiric antispasmodics for all types of abdominal pain
esplly in HSP / urticarial vasculitis , chronic constipation & int.obst.
• Ask for top ( head ache) , mid ( abd colic) & bottom ( constipation)
• Empiric antacids / PPI for dyspepsia & not for colonic symptoms
• Check when was anthelmintics given before prescribing
• Don’t advice treament through phone without naked eye exam
( many miss intussusception , subacute intestinal obstruction )
41. Practitioner’s learning points( contd) DR.VSS
• FAP ( common ) , Psychogenic ( less common) & organic(rare)
• Focus on pain details , red flags & psychic triggers
• Common causes for CAP : Retentive constipation , GERD , erosive
gastritis , abdominal migraine , dysmenorrhoea , pancreatitis PCOD ,
lactose intolerance / food allergy SRU ,UTI , Crohn’s , psychogenic
* Diagnosis not that easy in children < 4 years of age , lot of issues ??
• Be clear about incidental GB stoes , mesenteric RLQ lymphadenitis
& probe tenderness RLQ (appendicitis ) in USG abd reports
• Clinical dignosis more useful than lab investications in FAP
42. TAKE HOME MESSAGE
The wise clinician will make a careful
evaluation based first & foremost on a
thorough history & physical exam
supplemented as appropriate by prudently
targeted investigations
Thank you
