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

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

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

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

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

SOILING WITHOUT CONSTIPATION WITH CONSTIPATION MENTAL RETARDATION

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

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

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

DEFECATION RECTAL FILLING PROPULSION OF RECTAL CONTENTS

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

ANAL SPHINCTER INTERNAL EXTERNAL INVOLUNTARY VOLUNTARY

INCREASING INTRA ABDOMINAL INHIBITION IN MUSCLE ACTIVITY OF THE PELVIC ANORECTAL ANGLE INCREASE 80 0 TO 140 O DUE TO RELAXATION OF THE PUBORECTAL MUSCLE

NORMAL DEFECATION INVOLVES SYNCHRONIZED INVOLUNTARY AND VOLUNTARY FUNCTIONS

CONSTIPATION IMPAIRED RECTAL FILLING IMPAIRED RECTAL PROPULSION

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

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

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

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

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

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

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

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

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

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

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

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

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

CHRONIC TREATMENT-RESISTANT CONSTIPATION IDIOPATHIC ORGANIC IDIOPATHIC ORGANIC FUNCTIONAL FUNCTIONAL

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

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

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