Presentation on theme: "John T. Stutts, MD, MPH University of Louisville Department of Pediatrics Division of Pediatric Gastroenterology."— Presentation transcript:
John T. Stutts, MD, MPH University of Louisville Department of Pediatrics Division of Pediatric Gastroenterology
LOUISVILLE.EDU The speaker has been a part of the speaker bureau for Abbott Nutrition in the past. D ISCLOSURE
LOUISVILLE.EDU Constipation: “A delay or difficulty in defecation, present for ≥ 2 weeks and sufficient to cause significant distress to the patient.” 1 Encopresis: “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 D EFINITION
LOUISVILLE.EDU As many as 3% of visits to the primary care physician. 1 As many as 25% of visits to the pediatric gastreoenterologist. 1 16 – 37% of otherwise healthy 4 to 11 year old children have constipation. 2-6 C ONSTIPATION : P REVALENCE
LOUISVILLE.EDU Constipation is the #1 cause of abdominal pain. If the chief complaint is abdominal pain …. think constipation until proven otherwise. I N Y OUR C LINIC …..
LOUISVILLE.EDU I N Y OUR C LINIC ….. 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?
LOUISVILLE.EDU Functional Constipation -An umbrella term describing persistent, difficult, infrequent or seemingly incomplete defecation without evidence of a primary anatomic or biochemical cause. 7 -Accounts 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 F UNCTIONAL VS. O RGANIC
LOUISVILLE.EDU 3 critical time periods -Introduction of cereals/solids -Toilet training -Start of school F UNCTIONAL : E TIOLOGY
LOUISVILLE.EDU 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 F UNCTIONAL
LOUISVILLE.EDU Fecal Incontinence -In children with constipation, there is no clear difference in the pathophysiology or psychology between children with and without fecal incontinence. 9 F UNCTIONAL
LOUISVILLE.EDU 2 phases to treatment -Phase 1: The Cleanout -Phase 2: Maintenance Phase 1 is arguably the most important! F UNCTIONAL : T REATMENT
LOUISVILLE.EDU Enemas -Phosphate Enemas Adult (≥ 3 yoa) Pediatric (< 3 yoa) -SMOG (Saline, Mineral Oil, Glycerin) -Milk and Molasses Magnesium Citrate -1 oz per year of age to a max of 10oz -once daily x 3-6 days -not for infants/toddlers Polyethylene glycol -“multiple doses” vs “the gallon” F UNCTIONAL : C LEANOUT O PTIONS
LOUISVILLE.EDU Osmotic -Polyethylene glycol (1 capful = 17 grams) 3 yoA½ capful Q day 6 yoA½ capful BID *10 yoA1 capful BID 13 yoA1 – 1 ½ capfuls BID 18 yoA1 – 2 capfuls BID F UNCTIONAL : M AINTENANCE O PTIONS
LOUISVILLE.EDU Osmotic -Milk of Magnesia ≤ 1 year1-2 tsp BID 2 – 6 years2 tsp BID 7-8 years1 T BID ≥ 9 years2 T BID -Lactulose 1 – 3 mL/kg/day F UNCTIONAL : M AINTENANCE O PTIONS
LOUISVILLE.EDU Fiber is the KEY! Wean the laxative slowly!! H OW DO WE COME OFF THE L AXATIVE ? AGEDOSE 1 – 3 years15 grams/day 4 – 8 years20 grams/day 9 – 12 years25 grams/day ≥ 13 years30 grams/day
LOUISVILLE.EDU The question of Organic etiology… S O WHEN IS IT MORE THAN JUST CFC?
LOUISVILLE.EDU Organic causes are responsible for fewer than 5% of cases of constipation in children. O RGANIC C ONSTIPATION
LOUISVILLE.EDU Anatomic -Anal stenosis -Imperforate anus -Anteriorly displaced anus -Pelvic mass (sacral teratoma) Metabolic -Hypothyroidism -Hypercalcemia -Hypokalemia -Cystic Fibrosis -Diabetes Mellitus -Celiac disease -MEN type 2B O RGANIC C ONSTIPATION Neuropathic -Tethered cord Intestinal nerve/muscle disorder -Hirschsprung's disease -Visceral myopathies Abnormal abdominal musculature -Prune-belly -Down syndrome -Gastroschisis Connective tissue disorders -Scleroderma
LOUISVILLE.EDU Medications -Opiates -Antacids -Phenobarbital Miscellaneous -Cow’s milk protein intolerance -Lead ingestion -Botulism 10,11 O RGANIC C ONSTIPATION
LOUISVILLE.EDU 0.3 – 7.5% of normal infants Think about this in the infant who has constipation in association with rhinitis, dermatitis or bronchospasm Options: -Dairy elimination for the breast feeding mother -Casein Hydrolysate formulas -Elemental amino acid-based formulas 12,13 C OW ’ S M ILK P ROTEIN A LLERGY /I NTOLERANCE
LOUISVILLE.EDU 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 H IRSCHSPRUNG ' S DISEASE
LOUISVILLE.EDU 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 H IRSCHSPRUNG ' S DISEASE
LOUISVILLE.EDU Consider in the following circumstances: -Delayed passage of meconium (after 48 hours of life) -Abdominal distention -Vomiting -Onset of symptoms in the first week of life -A transition zone on contrast enema 14 H IRSCHSPRUNG ' S DISEASE The “classic triad” present in 82% of cases.
LOUISVILLE.EDU Rectal exam – The “Wine Goblet” Explosion… H IRSCHSPRUNG ' S DISEASE : D IAGNOSIS VS H.D. CFC
LOUISVILLE.EDU Unprepped contrast enema -If H.D. present, a transition zone will be seen ~ 70% of the time. Anorectal manometry -When the rectal balloon is inflated, reflex relaxation of the internal anal sphincter fails to occur. H IRSCHSPRUNG ' S DISEASE : D IAGNOSIS
LOUISVILLE.EDU Rectal suction or full-thickness biopsy ═ The definitive test -absence of ganglion cells -high acetylcholinesterase accumulation on staining H IRSCHSPRUNG ' S DISEASE : D IAGNOSIS
LOUISVILLE.EDU Constipation is common DIOS = Distal Ilial Obstruction Syndrome C YSTIC F IBROSIS
LOUISVILLE.EDU 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. T ETHERED C ORD S YNDROME
LOUISVILLE.EDU Associated signs/symptoms -constipation -bladder dysfunction -weak lower extremity reflexes Diagnosis -MRI of the lumbosacral spine Treatment -Neurosurgical release T ETHERED C ORD S YNDROME
LOUISVILLE.EDU If since the neonatal period, there has been constipation (especially with delayed passage of meconium)…. do an unprepped contrast enema. O RGANIC P EARLS
LOUISVILLE.EDU If a patient has recurrent UTIs, consider constipation as an etiology due to mechanical effects of the distended rectum pressing on the bladder. O RGANIC P EARLS
LOUISVILLE.EDU If the patient has FTT, RAP and constipation (+/- anemia), consider celiac disease. O RGANIC P EARLS
LOUISVILLE.EDU If 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. O RGANIC P EARLS
LOUISVILLE.EDU If there is impaired linear growth and depressed reflexes…. consider hypothyroidism. O RGANIC P EARLS
LOUISVILLE.EDU If at risk of electrolyte disturbances (metabolic abnormalities or unable to tolerate adequate fluids)….. check a serum Calcium. O RGANIC P EARLS
LOUISVILLE.EDU If at risk for lead toxicity…. test for it. O RGANIC P EARLS
LOUISVILLE.EDU If 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. O RGANIC P EARLS
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