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John T. Stutts, MD, MPH University of Louisville Department of Pediatrics Division of Pediatric Gastroenterology.

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Presentation on theme: "John T. Stutts, MD, MPH University of Louisville Department of Pediatrics Division of Pediatric Gastroenterology."— Presentation transcript:

1 John T. Stutts, MD, MPH University of Louisville Department of Pediatrics Division of Pediatric Gastroenterology

2 LOUISVILLE.EDU The speaker has been a part of the speaker bureau for Abbott Nutrition in the past. D ISCLOSURE

3 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

4 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

5 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 …..

6 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?

7 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

8 LOUISVILLE.EDU 3 critical time periods -Introduction of cereals/solids -Toilet training -Start of school F UNCTIONAL : E TIOLOGY

9 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

10 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

11 LOUISVILLE.EDU 2 phases to treatment -Phase 1: The Cleanout -Phase 2: Maintenance Phase 1 is arguably the most important! F UNCTIONAL : T REATMENT

12 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

13 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

14 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

15 LOUISVILLE.EDU Lubricant -Mineral Oil Not recommended Lipoid pneumonia if aspirated Stimulant -Senna ≤ 2 yrs¼ - 1 tsp BID 2 – 4 yrs½ - 1 tsp BID 5 – 6 yrs1 tsp BID 7 – 9 yrs1 tablet BID ≥ 10 yrs2 tablets BID F UNCTIONAL : M AINTENANCE O PTIONS

16 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

17 LOUISVILLE.EDU The question of Organic etiology… S O WHEN IS IT MORE THAN JUST CFC?

18 LOUISVILLE.EDU Organic causes are responsible for fewer than 5% of cases of constipation in children. O RGANIC C ONSTIPATION

19 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

20 LOUISVILLE.EDU Medications -Opiates -Antacids -Phenobarbital Miscellaneous -Cow’s milk protein intolerance -Lead ingestion -Botulism 10,11 O RGANIC C ONSTIPATION

21 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

22 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

23 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

24 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.

25 LOUISVILLE.EDU Rectal exam – The “Wine Goblet” Explosion… H IRSCHSPRUNG ' S DISEASE : D IAGNOSIS VS H.D. CFC

26 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

27 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

28 LOUISVILLE.EDU Constipation is common DIOS = Distal Ilial Obstruction Syndrome C YSTIC F IBROSIS

29 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

30 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

31 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

32 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

33 LOUISVILLE.EDU If the patient has FTT, RAP and constipation (+/- anemia), consider celiac disease. O RGANIC P EARLS

34 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

35 LOUISVILLE.EDU If there is impaired linear growth and depressed reflexes…. consider hypothyroidism. O RGANIC P EARLS

36 LOUISVILLE.EDU If at risk of electrolyte disturbances (metabolic abnormalities or unable to tolerate adequate fluids)….. check a serum Calcium. O RGANIC P EARLS

37 LOUISVILLE.EDU If at risk for lead toxicity…. test for it. O RGANIC P EARLS

38 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

39 Thank you!

40 R EFERENCES 1.Baker SS, Liptak GS, Colletti RB, Constipation in infants and children: evaluation and treatment. J Ped Gastro Nutr 1999;29(5):612-626. 2.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):679-682. 3.Yong D, Beattie RM. Normal bowel habit and prevalence of constipation in primary school children. Amb Child Health 1998;4:277-282. Araújo Sant’Anna AM, Cal ҫ ado AC. Constipation in school-aged children at public schools in Rio de Janeiro, Brazil. J Ped Gastroenterol Nutr 1999;29(2):190-193. 5.Zaslavsky C, Ávila EL, Araújo MA, et. al. Constipa ҫ ão intestinal da infância – um estudo de prevalência. Rev AMRIGS 1988;32:100-102. 6.Maffei HVL, Moreira FL, Oliveira WM, et. al. Constipa ҫ ão intestinal em escolare. J Pediatr 1997;73:340-344. 7. Thompson WG, Longstreth GF, Drossman DA, et. al. Functional bowel disorders and functional abdominal pain. Gut 1999;45:1143. 8. Hyman PE, Milla PJ, Benninga MA, et. al. Childhood functional gastrointestinal disorders: neonate/toddler. Gastroenterology 2006;130:1519. 9. Benninga MA, Bϋller HA, Heymans HS, et. al. Is encopresis always the result of constipation? Arch Dis Child 1994;71:186. 10. DiLorenzo C. Pediatric anorectal disorders. Gastroenterol Clin North Am 2001;30:269. 11. Thiessen PN. Recurrent abdominal pain. Pediatr Rev 2002;23:39. 12. Magazzu G, Scoglio R. Gastrointestinal manifestations of cow’s milk allergy. Ann Allergy Asthma Immunol 2002;89:65. 13. Turunen, et al. Lymphoid hyperplasia and cow’s milk hypersensitivity in children with chronic constipation. J Pediatr 2004;145:606. 14. Lewis NA, et. al. Diagnosing Hirschsprung’s disease: increasing the odds of a positive rectal biopsy result. J Pediatr Surg 2003;38:412.

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