this presentation is all about the constipation in children, how we evaluate history and what steps should be taken for treatment.

2. Approach to a Child with Constipation and Encopresis What’s Problem with me?? Dr. SaimaBahir Post Graduate Trainee Pediatric Medicine Unit- I

3. OBJECTIVE Causes of constipation in children Differentiate organic from non organic causes Identify red flag sign Plan out Investigation

4. NORMAL STOOL FREQUENCY The normal frequency of bowel movements at different ages has been defined. Infants have a mean of 4 stools per day during the first week of life. 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 Some normal breast-fed babies do not have stools for several days or longer. After 4 years,the frequency of bowel movements remains unchanged

5. DEFINITION OF CONSTIPATION “A delay or difficulty in defecation, present for two or more weeks, sufficient to cause significant distress to the patient.” (North American Society for Pediatric Gastroenterology)

6. DEFINITION OF ENCOPRESIS 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

7. TYPES OF ENCOPRESIS Retentive encopresis: Seepage of liquid stool around the fecal mass in a chronically distended rectum. Non retentive encopresis: 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

8. DEFINITION BY PaCCT GROUP The occurrence of two or more of the following characteristics during the past eight weeks: Frequency of bowel movements less than three per week More than one episode of faecal incontinence per week Large stools in the rectum or palpable on abdominal examination Passing of stools so large that they may obstruct the toilet Display of retentive posturing and withholding behaviours Painful defecation

9. EPIDEMIOLOGY EPIDEMIOLOGY The exact worldwide prevalence in children is not known. 0.3% to 28% of children worldwide are constipated. Constipation occurs in all social classes. Much more common in boys than in girls

10. PATHOPHSIOLOGY

11. E T I O L O G Y Intestinal muscle or nerve problem Hirschsprung disease Pseudo-obstruction (visceral myopathy or neuropathy) Intestinal neuronal dysplasia Spinal cord abnormalities: myelomeningocele, spina bifida, tethered cord Metabolic causes: hypothyroidism, hypercalcemia, hypokalemia,diabetesinsipidus Heavy-metal poisoning (lead) Medication side effects (vitamin D intoxication, pancreatic enzymes) INFANTS Anatomic Congenital anorectal malformation (Anal stenosis,Imperforateanus,Anteriorly displaced anus) Intestinal stricture (post necrotizing enterocolitis) Abnormal musculature Prune belly syndrome Gastroschisis Down syndrome Cystic fibrosis Cow’s milk protein intolerance

12. Spinal cord abnormalities: Spinal cord trauma, tumor Metabolic causes: hypothyroidism, hypercalcemia, hypokalemia, diabetes mellitus, diabetes insipidus Neurological Neurofibromatosis Developmental delays Heavy-metal poisoning (lead) Medication side effects (vitamin D intoxication, pheno, antihypertensive, pancreatic enzymes, antidepressants, chemo vincristine) Connective Tissue Disorders Systemic lupus Erythematosus Scleroderma Psychiatric Diagnosis Anorexia nervosa Spinal cord abnormalities: Spinal cord trauma, tumor Metabolic causes: hypothyroidism, hypercalcemia, hypokalemia, diabetes mellitus, diabetes insipidus Neurological Neurofibromatosis Developmental delays Heavy-metal poisoning (lead) Medication side effects (vitamin D intoxication, pheno, antihypertensive, pancreatic enzymes, antidepressants, chemo vincristine) Connective Tissue Disorders Systemic lupus Erythematosus Scleroderma Psychiatric Diagnosis Anorexia nervosa Children more than 1yr Functional constipation in more than 95% Anatomic Intestinal stricture (post necrotizing enterocolitis) Abnormal musculature Down syndrome Intestinal disorder Cystic fibrosis Gluten enteopathy Inflammatory bowel disease (strictures) Tumors Intestinal muscle or nerve problem Hirschsprung disease Cow’s milk protein intolerance

13. Children more than 1yr Functional / Non-organic causes Developmental Cognitive handicaps Attention-deficit disorders Situational Coercive toilet training Toilet phobia School bathroom avoidance Excessive parental interventions Sexual abuse Other Depression Constitutional Colonic inertia Genetic predisposition Reduced stool volume and dryness Low fiber in diet Dehydration Underfeeding or malnutrition

14. EVALUATION History Physical examination Investigation To identify organic causes for constipation Identify red flag signs

15. HISTORY HISTORY Age and Sex Chief symptom Constipation history Frequency and consistency of stools Pain or bleeding with passing stools Abdominal pain Waxing and waning of symptoms Age of onset Toilet training Fecal soiling Withholding behavior Change in appetite

16. Nausea or vomiting Weight loss Perianal fissures, dermatitis, abscess, or fistula Current treatment Current diet (24-hour recall history) Current medications (for all medical problems) Oral, enema, suppository, herbal Previous treatment Diet Medications: Oral, enema, suppository, herbal Prior successful treatments Behavioral treatment Results of prior tests Estimate of parent/patient adherence

17. Medical history Gestational age Time of passage of meconium Condition at birth Acute injury or disease Hospital admissions Surgeries Delayed growth and development Features of hypothyroidism: Sensitivity to cold, Coarse hair, Dry skin Recurrent urinary tract infections Daytime urinary incontinence Developmental history Normal, delayed School performance

18. Detailed dietary history Psychosocial history Psychosocial disruption of child or family Interaction with peers Temperament Toilet habits at school Family history Significant illnesses Gastrointestinal (constipation, Hirschsprung disease) Thyroid, parathyroid, cystic fibrosis, celiac disease

19. PHYSICAL EXAMINATION PHYSICAL EXAMINATION General appearance Vital signs Temperature Pulse Respiratory rate Blood pressure Growth parameters Head, ears, eyes, nose, throat Neck (goiter, lymhnodes) General appearance Vital signs Temperature Pulse Respiratory rate Blood pressure Growth parameters Head, ears, eyes, nose, throat Neck (goiter, lymhnodes)

20. PHYSICAL EXAMINATION PHYSICAL EXAMINATION General appearance Vital signs Temperature Pulse Respiratory rate Blood pressure Growth parameters Head, ears, eyes, nose, throat Neck (goiter, lymhnodes) Abdomen Distension Palpable liver and spleen Fecal mass Anal inspection Position Stool present around anus or on clothes Perianalerythema Skin tags Anal fissures Rectal examination Anal tone Fecal mass Presence of stool Consistency of stool Other masses Explosive stool on withdrawal of finger

21. PHYSICAL EXAMINATION PHYSICAL EXAMINATION General appearance Vital signs Temperature Pulse Respiratory rate Blood pressure Growth parameters Head, ears, eyes, nose, throat Neck (goiter, lymhnodes) Back and spine examination Dimple Tuft of hair Neurological examination Tone Strength Cremasteric reflex Deep tendon reflexes Cardiovascular Lungs and chest

22. RED FLAG SIGN FOR ORGANIC DISEASE Failure to thrive Abdominal distension Pilonidal dimple covered by a tuft of hair Midline pigmentary abnormalities of the lower spine Lack of lumbosacral curve Sacral agenesis Flat buttocks Anteriorly displaced anus Patulous anus

23. Red flag sign for organic disease Tight, empty rectum in presence of palpable abdominal fecal mass Gush of liquid stool and air from rectum on withdrawal of finger Occult blood in stool Absent anal wink Absent cremasteric reflex Decreased lower extremity tone and/or strength Absence or delay in relaxation phase of lower extremity deep-tendon reflexes

24. FINDINGS CONSISTENT WITH FUNCTIONAL CONSTIPATION History Stool passed within 48 hours of birth Extremely hard stools, large-caliber stools Fecal soiling (encopresis) Pain or discomfort with stool passage; withholding of stool Blood on stools; perianal fissures Decreased appetite, waxing and waning of abdominal pain with stool passage

25. Findings consistent with functional constipation Diet low in fiber or fluids, high in dairy products Hiding while defecating before toilet training is completed; avoiding the toilet Physical examination Mild abdominal distention; palpable stool in left lower quadrant Normal placement of anus; normal anal sphincter tone Rectum packed with stool; rectum distended Presence of anal wink and cremasteric reflex

26. INVESTIGATION Most children require no investigation CBC Plain radiograph of abdomen for fecal impaction Stool examination for occult blood Other specific test Barium enema Colonoscopy Hirshprung disease Barium enema in unprepared gut Rectal biopsy Anorectalmanometry

27. INVESTIGATION Thyroid function test Celiac antibodies Serum electrolyte (Na, K, Ca) Spinal cord problem X-ray spine MRI Spine Cystic fibrosis

28. Infant with signs or symptoms suggestive of constipation Red flag sign for organic disease yes No Evaluate for organic disease Diagnosis for functional constipation

29. ENCOPRESIS

30. PATHOPHSIOLOGY OF ENCOPRESIS In the vast majority of cases, encopresis develops as a consequence of chronic constipation with resulting overflow incontinence which is typically termed retentive encopresis. Boys are more commonly effected.

31. CAUSES 95% of cases no organic cause Constipation 80% Non retentive 20% Anorectal malformation Spinal cord problem Meningomyelocele Spina bifid

32. HISTORY Age and Sex Soiling history Age of onset of symptom Age of bowel and bladder control Toilet trained for more than 6 mon Frequency-Episodes per week or month Time of the day (day, night, school) Constipation Pain with defecation Treatment taken and effectiveness

33. HISTORY Medical history Delayed meconium passage Any previous illness Spinal cord problem Developmental history Detailed dietary history Psychosocial history Psychosocial disruption of child or family Interaction with peers

34. HISTORY Approximately 80-95% of children with encopresis have a history of constipation or painful defecation. 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. As evidence of functional megacolon, many children with retentive encopresis intermittently pass extremely large bowel movements.

35. EXAMINATION Physical findings, other than those obtained from the abdominal and rectal examinations, are usually normal. Abdominal examination: Stool can be palpated most notably in left lower quadrant. Rectal examination: Anal tone Fecal mass Consistency of stool Explosive stool on withdrawal of finger Neurologic findings: Anal wink Sensation, strength, and reflexes in the lower extremities.

36. INVESTIGATION In most patients, the diagnosis of encopresis is established with the history and complete physical examination, including a rectal examination. Laboratory studies are rarely warranted. Plain abdominal radiograph Soft fecal impaction Anorectalmanometry Rectal biopsy

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