Presentation on theme: "THE SCOOP ON POOP Management of the Constipated Patient in the Pediatric Setting John T. Stutts, MD, MPH University of Louisville Department of Pediatrics."— Presentation transcript:
1THE SCOOP ON POOP Management of the Constipated Patient in the Pediatric Setting John T. Stutts, MD, MPHUniversity of Louisville Department of PediatricsDivision of Pediatric Gastroenterology
2DisclosureThe speaker has been a part of the speaker bureau for Abbott Nutrition in the past.
3DefinitionConstipation: “A delay or difficulty in defecation, present for ≥ 2 weeks and sufficient to cause significant distress to the patient.”1Encopresis: “The involuntary loss of formed, semi-formed, or liquid stool in the child’s underwear, in the presence of functional constipation after the child has reached a developmental age of 4 years.”1
4Constipation: Prevalence As many as 3% of visits to the primary care physician.1As many as 25% of visits to the pediatric gastreoenterologist.116 – 37% of otherwise healthy 4 to 11 year old children have constipation.2-6
5In Your Clinic ….. Constipation is the #1 cause of abdominal pain. If the chief complaint is abdominal pain …. think constipation until proven otherwise.
6In Your Clinic ….. A question not to ask: Is your child constipated?A better question that will give you a clearer picture:How many days does your child skip between bowel movements?
7Functional vs. Organic Functional Constipation An umbrella term describing persistent, difficult, infrequent or seemingly incomplete defecation without evidence of a primary anatomic or biochemical cause.7Accounts for greater than 95% of constipation-related symptoms in children and infants, except those during the neonatal period when organic causes are more likely.7
8Functional: Etiology 3 critical time periods Introduction of cereals/solidsToilet trainingStart of school
9Functional Infant Dyschezia At least 10 minutes of straining and/or crying before successful passage of soft stool in an otherwise healthy infant < 6 mos of age.The symptom is due to failure to relax the pelvic floor during the defecation effort and resolves spontaneously.8
10Functional Fecal Incontinence In children with constipation, there is no clear difference in the pathophysiology or psychology between children with and without fecal incontinence.9
11Functional: Treatment 2 phases to treatmentPhase 1: The CleanoutPhase 2: MaintenancePhase 1 is arguably the most important!
12Functional: Cleanout Options EnemasPhosphate EnemasAdult (≥ 3 yoa)Pediatric (< 3 yoa)SMOG (Saline, Mineral Oil, Glycerin)Milk and MolassesMagnesium Citrate1 oz per year of age to a max of 10ozonce daily x 3-6 daysnot for infants/toddlersPolyethylene glycol“multiple doses” vs “the gallon”
21Cow’s Milk Protein Allergy/Intolerance 0.3 – 7.5% of normal infantsThink about this in the infant who has constipation in association with rhinitis, dermatitis or bronchospasmOptions:Dairy elimination for the breast feeding motherCasein Hydrolysate formulasElemental amino acid-based formulas12,13
22Hirschsprung's disease More than 90% of normal infants, but only 10% of infants with Hirschsprung's disease, pass meconium within the first 24 hours of life.14
23Hirschsprung's disease A motor disorder of the colon caused by failure of neural crest cells to migrate completely during colonic development.The result … the affected segment of the colon fails to relax causing a functional obstruction.14
24Hirschsprung's disease Consider in the following circumstances:Delayed passage of meconium (after 48 hours of life)Abdominal distentionVomitingOnset of symptoms in the first week of lifeA transition zone on contrast enema14The “classic triad” present in 82% of cases.
26Hirschsprung's disease: Diagnosis Unprepped contrast enemaIf H.D. present, a transition zone will be seen ~ 70% of the time.Anorectal manometryWhen the rectal balloon is inflated, reflex relaxation of the internal anal sphincter fails to occur.
27Hirschsprung's disease: Diagnosis Rectal suction or full-thickness biopsy═ The definitive testabsence of ganglion cellshigh acetylcholinesterase accumulation on staining
28Cystic Fibrosis Constipation is common DIOS = Distal Ilial Obstruction Syndrome
29Tethered Cord Syndrome What is it exactly?Stretch-induced dysfunction of the caudal spinal cord and conus caused by attachment of the filum terminale to inelastic structures caudally.
30Tethered Cord Syndrome Associated signs/symptomsconstipationbladder dysfunctionweak lower extremity reflexesDiagnosisMRI of the lumbosacral spineTreatmentNeurosurgical release
31Organic PearlsIf since the neonatal period, there has been constipation (especially with delayed passage of meconium)…. do an unprepped contrast enema.
32Organic PearlsIf a patient has recurrent UTIs, consider constipation as an etiology due to mechanical effects of the distended rectum pressing on the bladder.
33Organic PearlsIf the patient has FTT, RAP and constipation (+/- anemia), consider celiac disease.
34Organic PearlsIf there is spinal dysraphism or neurological impairment of the lower extremities and/or daytime wetting in association with constipation, obtain an MRI of the lumbosacral spine.
35Organic PearlsIf there is impaired linear growth and depressed reflexes…. consider hypothyroidism.
36Organic PearlsIf at risk of electrolyte disturbances (metabolic abnormalities or unable to tolerate adequate fluids)….. check a serum Calcium.
37Organic PearlsIf at risk for lead toxicity…. test for it.
38Organic PearlsIf the H & P remains equivocal for etiology, don’t be afraid to get a KUB …. but remember the readings can be inconsistently interpreted. So, don’t be afraid to look at the film yourself.
40ReferencesBaker SS, Liptak GS, Colletti RB, et.al. Constipation in infants and children: evaluation and treatment. J Ped Gastro Nutr 1999;29(5):Issenman RM, Hewson S, Pirhonen D, et. al. Are chronic digestive complaints the result of abnormal dietary patterns? Am J Dis Child 1987;141(6):Yong D, Beattie RM. Normal bowel habit and prevalence of constipation in primary school children. Amb Child Health 1998;4:de Araújo Sant’Anna AM, Calҫado AC. Constipation in school-aged children at public schools in Rio de Janeiro, Brazil. J Ped Gastroenterol Nutr 1999;29(2):Zaslavsky C, Ávila EL, Araújo MA, et. al. Constipaҫão intestinal da infância – um estudo de prevalência. Rev AMRIGS 1988;32:Maffei HVL, Moreira FL, Oliveira WM, et. al. Constipaҫão intestinal em escolare. J Pediatr 1997;73:Thompson WG, Longstreth GF, Drossman DA, et. al. Functional bowel disorders and functional abdominal pain. Gut 1999;45:1143.Hyman PE, Milla PJ, Benninga MA, et. al. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology 2006;130:1519.Benninga MA, Bϋller HA, Heymans HS, et. al. Is encopresis always the result of constipation? Arch Dis Child 1994;71:186.DiLorenzo C. Pediatric anorectal disorders. Gastroenterol Clin North Am 2001;30:269.Thiessen PN. Recurrent abdominal pain. Pediatr Rev 2002;23:39.Magazzu G, Scoglio R. Gastrointestinal manifestations of cow’s milk allergy. Ann Allergy Asthma Immunol 2002;89:65.Turunen, et al. Lymphoid hyperplasia and cow’s milk hypersensitivity in children with chronic constipation. J Pediatr 2004;145:606.Lewis NA, et. al. Diagnosing Hirschsprung’s disease: increasing the odds of a positive rectal biopsy result. J Pediatr Surg 2003;38:412.