1. Atan Baas Sinuhaji Sub Division of Pediatrics Gastroentero-Hepatolgy Department of ChildHealth,School of Medicine University of Sumatera Utara CONSTIPATION MEDAN

2. DEFECATION REGULAR PATTERN CONSTIPATION GOOD HEALTH BACKUP OF STOOLS ACCUMULATION OF TOXIN IN THE BLOOD ACCUMULATION OF TOXIN IN THE BLOOD

3. DEFINITION OF CONSTIPATION VARIES AMONG INDIVIDUAL VARIES AMONG INDIVIDUAL HARD LARGE INFREQUENT PAIN OR STOOLS STOOLS STOOLS PRESSURE HARD LARGE INFREQUENT PAIN OR STOOLS STOOLS STOOLS PRESSURE WHILE STOOLING WHILE STOOLING

4. CONSTIPATION FREQ. DEFECATION  - HARD, DRY STOOLS - DIFFICULT / PAIN - INCONTINENCE = SOILING = ENCOPRESIS

5. FREQUENCY OF DEFECATION NORMAL = 2 X / DAY- 1 X/2DAYS ABNORMAL < 1 X / 2 DAYS

6. SOILING WITHOUT CONSTIPATION WITH CONSTIPATION MENTAL RETARDATION

7. CLASSIFICATION 1. ACUTE / CHRONIC (  3 MONTHS ) 2. SEVERITY 3. ORGANIC / IDIOPATHIC 4. PATHOGENESIS 5. ANORECTAL DYSFUNCTION (+)/(-) 6.OBSTRUCTIVE / FUNCTIONAL 7. CONGENITAL / ACQUIRED

8. ORGANIC 1.SYSTEMIC @ DRUGS @ ENDOCRINE AND METABOLIC DISORDERS @ OTHERS ( faulty diet or bowel habit, long distance travel ) 2.NEUROGENIC 3.OBSTRUCTIVE LESION 4.FUNCTIONAL CONSTIPATION @ ABNORMALITIES OF MUSCLE FUNCTION (eg.COLONIC INERTIA) @ ANORECTAL OR PELVIC FLOOR DISORDERS @ PSYCHOLOGICAL DISEASES

9. Rome III Functional constipation At least once per week for at least 2 months before diagnosis. Must included ≥ 2 of following criteria. 1. ≤ 3 defecations / wk 2.  1 episode of fecal incontinence/wk 3. Retentive posturing or excessive volitional stool retention 4. History of painful or hard bowel movements 5. Presence of a large fecal mass in the rectum 6. History of large diameter stools which can obstruct the toilet

10. DEFECATION RECTAL FILLING PROPULSION OF RECTAL CONTENTS

11. - CONTRACTION - RECTAL PRESSURE - URGE TO DEFECATE - RELAXING THE ANAL SPHINCTER - STRAINING - DISTENTION PROPULSION OF RECTAL CONTENTS

12. ANAL SPHINCTER INTERNAL EXTERNAL INVOLUNTARY VOLUNTARY

13. STRAINING @ INCREASING INTRA ABDOMINAL PRESSURE @ INHIBITION IN MUSCLE ACTIVITY OF THE PELVIC FLOOR @ ANORECTAL ANGLE INCREASE 80 0 TO 140 O DUE TO RELAXATION OF THE PUBORECTAL MUSCLE

15. NORMAL DEFECATION INVOLVES SYNCHRONIZED INVOLUNTARY AND VOLUNTARY FUNCTIONS

16. CONSTIPATION IMPAIRED RECTAL FILLING IMPAIRED RECTAL PROPULSION

17. IMPAIRED RECTAL FILLING IMPAIRED PERISTALSIS OBSTRUCTION DRUGS HORMONAL MORBUS HIRSCHSPRUNG -SPASMOLYTIC -CODEIN HYPOTHYROIDISM

18. IMPAIRED RECTAL PROPULSION 1.PERISTALSIS 2.OBSTRUCTION 3.SENSATION (SPINAL CORD LESION, etc) 4.RELAXATION OF ANAL SPHINCTER (ANAL FISSURE, STENOSIS) 5.ABNORMALITY OF ABDOMINAL/ PELVIC WALL 6.ABNORMALITY OF AUTONOMIC & CORTICAL CONTROL 7.ABNORMALITY OF ANAL CANAL

19. PRECIPITATING EVENT UNEXPELLED STOOLS FUTHER STOOL RETENTION & SOILING RECTAL DISTENTION PAIN AND WITH HOLDING DEPRESSED ANORECTAL REFLEX ANAL FISSURENO URGE TO STOOL HARD STOOLS WATER REABSORBSTION

20. WITHHOLD STOOLS =PAIN  FISSURE =LACK OF TIME =POOR HYGIEN =NET ALLOWED  SCHOOL

21. CONSEQUENCES 1.VOMITING 2.ABDOMINAL PAIN 3.ABDOMINAL DISTENTION 4.PAIN TO DEFECATE 5.RECTAL BLEEDING  ANAL FISSURE 6.ANOREXIA 7.ABDOMINAL MASS  RETENTION OF URINE 8.CHRONIC - PCM - MEGACOLON

22. MEGACOLON CONGENITAL AGANGLIONIC = M. HIRSCHSPRUNG IDIOPATHIC = ACQUIRED = CHRONIC IDIOPATHIC CONSTIPATION MEGACOLON STOOLS PARADOXAL DIARRHOEA Ganglion (-) Peristalsis Obstruction External Anal Sphincter INCONTINENTIA ALVI BARIUM IN LOOP

23. MEGACOLON IDIOPATHIC= ACQUIREDCONGENITAL 1.ONSET 2-3 YEARS 1 ST DAY 2.SOILING (+) (-) 3.PARADOXAL (-) (+) DIARRHOEA 4.PCM (-) (+) 5.ABD. DISTENTION (+) (++) 6.ANAL SPHINCTER LOOSE TIGHT 7.RECTAL AMPULLA FULL EMPTY 8.ENTEROCOLITIS (-) (+) 9.TREATMENT MEDICAL SURGERY

24. M. HIRSCHSPRUNG DIAGNOSIS IRRIGATION FULMINANT ENTEROCOLITIS OPERATION COLOSTOMY DEFINITIVE (6-12 MONTHS) DEATH

25. CHRONIC IDIOPHATIC CONSTIPATION 1. EVACUATION OF FIRM STOOLS (FECAL DISIMPACTION) MgSO 4 MgSO 4 IRRIGATION IRRIGATION etc etc 2. MAINTENANCE 1. DIETARY MANIPULATION  FIBERS >>> TAP WATER >>> TAP WATER >>> 2. TOILET TRAINING 3. DRUGS : a.SPASMOLYTIC (-) b.LAXANTIA : lactulose polyethylene glycol c. ANAEROB BACTERIAL: metronidazole

26. Behaviour therapy toilet training Start after the age of two 5 - 10 minutes Learn to take time to defecate Learn to push down After each meal  gastro - colic reflex Reward

27. OLD PARADIGM CHRONIC CONSTIPATION IS A BEHAVIOUR/LEARNING DISORDER CHRONIC CONSTIPATION IS A BEHAVIOUR/LEARNING DISORDER COMMON CAUSES COMMON CAUSES Behaviour / Learning Behaviour / Learning = Adverse life event = Adverse life event = Defiant behaviour = Defiant behaviour = Intellectual disability = Intellectual disability ( plus rare organic causes ) ( plus rare organic causes ) = Cystic fibrosis = Cystic fibrosis = Hirschsprung’s Disease = Hirschsprung’s Disease

28. NEW PARADIGM CHRONIC CONSTIPATION IS AN ORGANIC OR A BEHAVIOUR/LEARNING DISORDER CHRONIC CONSTIPATION IS AN ORGANIC OR A BEHAVIOUR/LEARNING DISORDER COMMON CAUSES COMMON CAUSES Behaviour / Learning Organic Behaviour / Learning Organic = Adverse life event = Colonic dysmotily = Adverse life event = Colonic dysmotily = Defiant behaviour = Outlet obstruction = Defiant behaviour = Outlet obstruction = Intellectual disability = Intellectual disability ( plus rare organic causes ) ( plus rare organic causes ) = Cystic fibrosis = Cystic fibrosis = Hirschsprung’s Disease = Hirschsprung’s Disease

29. IN 70 %AFFECTED CHILDREN,CONSTIPATION RESPONS WITHIN 2 YEARS OF DIAGNOSIS TO MEDICAL THERAPIES OR BEHAVIORAL MODIFICATION IN 70 %AFFECTED CHILDREN,CONSTIPATION RESPONS WITHIN 2 YEARS OF DIAGNOSIS TO MEDICAL THERAPIES OR BEHAVIORAL MODIFICATION THE REMAINING CHILDREN ARE CLASSIFIED WITH CHRONIC TREATMENT- RESISTANT CONSTIPATION THE REMAINING CHILDREN ARE CLASSIFIED WITH CHRONIC TREATMENT- RESISTANT CONSTIPATION

30. CHRONIC TREATMENT-RESISTANT CONSTIPATION IDIOPATHIC ORGANIC IDIOPATHIC ORGANIC FUNCTIONAL FUNCTIONAL

31. FUNCTIONAL COLONIC TRANSIT TIME NORMAL ABNORMAL HOLD UP AT ANO-RECTUM FUNCTIONAL FECAL REENTIONSLOW TRANSIT CONSTIPATION

32. DELAY IN COLONIC TRANSIT TIME DELAY IN COLONIC TRANSIT TIME INTRACTABLE CONSTIPATION INTRACTABLE CONSTIPATION NOT RESPONSE TO NOT RESPONSE TO LAXATIVE DIET CHANGE IN LIFE STYLE

33. CONCLUSIONS CONSTIPATION  COMMON PROBLEM DURING CHILDHOOD CONSTIPATION  COMMON PROBLEM DURING CHILDHOOD ACUTE FORM  EASILY CORRECTED ACUTE FORM  EASILY CORRECTED ACUTE FORM  NOT PROPERLY TREATED  CYCLE UNEXPELLED FECES BEGINS  COMPLICATION ACUTE FORM  NOT PROPERLY TREATED  CYCLE UNEXPELLED FECES BEGINS  COMPLICATION CHRONIC CONSTIPATION IS AN ORGANIC CAUSES NOT ONLY BEHAVIOUR/LEARNING DISORDER CHRONIC CONSTIPATION IS AN ORGANIC CAUSES NOT ONLY BEHAVIOUR/LEARNING DISORDER

34. SLOW TRANSIT CONSTIPATION DELAY IN COLONIC TRANSIT TIME DELAY IN COLONIC TRANSIT TIME INTRACTABLE CONSTIPATION INTRACTABLE CONSTIPATION NOT RESPONSE TO NOT RESPONSE TO LAXATIVE DIET CHANGE IN LIFE STYLE STYLE TERIMA KASIH