The Straight Poop… or how I learned to stop worrying and love the bomb Michael F. Ziegler, MD Assistant Professor Departments of Pediatrics and Emergency Medicine Emory University

Constipation ► Occurrence  3% of visits to Pediatricians  25% of visits to Gastroenterologists ► Definitions  Difficult or infrequent bowel movements  Painful defecation  Passage of hard stools  Sensation of incomplete evacuation of stool

North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) ► Constipation  “Delay or difficulty in defecation, present for two or more weeks and sufficient to cause significant distress to the patient” ► Baker, et al J Pediatr Gastroenterol Nutr 1999; 29

Paris Conference ► Constipation  Two or more of the following occurring over the preceeding 8 weeks: ► Frequency of BMs <3/week ► >1 episode of fecal incontinence/week ► Large stools in the rectum or palpable on the abdominal exam ► Passage of stools so large they obstruct the toilet ► Retentive posturing and withholding behavior ► Painful defecation ► Benninga, et al J Pediatr Gastroenterol Nutr 2009;40

Colon Physiology ► Muscular contractions propel and mix contents  Increased on waking and after meals (The Gastrocolic Reflex) ► Reabsorption of water and electrolytes mostly in cecum and transverse colon  Primarily water follows osmotic gradient as Na is absorbed through the lumenal wall  Adult colons can handle 1.5 liters of fluid per day with only cc water excreted  Under certain circumstances can handle 4.5 liters/day without causing diarrhea

Colon Physiology ► Rectal function  Material passes into rectum via propulsive contractions until rectum begins to dilate causing reflex relaxation of the internal anal sphincter and contraction of the rectal detrussor muscles

Rectal Function ► “I want to go”  The puborectalis muscle (forms the anorectal angle) and levator ani muscles relax straightening the anorectal angle  Straining increases intraabdominal pressure  Feces is expelled

Rectal Function ► “Not now, my date wants to cuddle”  Contract external anal sphincter  Prevents defecation and allows rectal wall to adapt to increased volume or reset for the next stimulation

Pathophysiology of Constipation ► Defective/Impaired Propulsion (<5%)  Diet deficient in bulk (fiber)  Milk Protein Allergy  Neuropathy/myopathy ► Cerebral palsy ► Spinal cord lesions  Metabolic ►  or  Ca;  K;  Mag;  Phos ► Hypothyroidism, Hyperparathyroidism ► Cystic fibrosis ► Celiac disease  Medications ► Narcotics ► Anticholinergics

Pathophysiology of Constipation ► Defective/Impaired Sensation  Primary sensory impairment such as spinal cord abnormalities (<5%)  Secondary sensory abnormalities such as megarectum from chronic fecal retention* ► Outlet Obstruction  Mechanical (<5%) ► Anal stenosis ► Hirshsprung’s Disease  Functional* ► *>95% of all constipation

Differentiating Organic Disease (<5%) ► Failure to thrive ► Abdominal distension +/- vomiting ► Anterior anus ► Tight anus ► Patulous anus ► Nevi or sinus in lumbosacral region ► Multiple Café-au-lait spots ► Abnormal tone or strength ► Abnormal lower extremity reflexes ► Blood in the stool

FunctionalOrganic Since birth NeverCommon Retentive posturing CommonUnusual EncopresisCommonRare Large caliber stools CommonUnusual Hx of obstruction RareCommon Failure to Thrive UnusualCommon Distended abdomen CommonOccasional Stool in ampulla CommonRare Rectal ampulla DilatedNarrow Functional vs Organic

Common presentations ROME II Diagnostic Criteria ► Infant Dyschezia  <6mo  Strains for ≥10 min  Passage of soft stools ► Basic regulatory mechanisms to control defecation present in newborn ► Failure to coordinate increased intraabdominal pressure with relaxation of pelvic floor ► Dissipates with development

Common presentations ROME II Diagnostic Criteria ► Functional constipation  Infants and preschool children  Associated with formula changes  No organic cause  Passing hard stools ≤ 2/week ► Use of fruit juices and medications with high sugar content softens stools and eases evacuation

Common presentations ROME II Diagnostic Criteria ► Functional Fecal Retention  Potty training and on  Retentive behavior  Defecation avoidance ► “The Poop Dance”  Anxious  Stiff body  Cross legs; walks on tip toes  Hop up and down  Runs to corner or hides behind couch ► Leads to fecal retention and overflow soiling

Functional Constipation with Encopresis ► Dilation of rectum leads to loss of normal sensation to defecate, however, internal sphincter still relaxed ► Stool remains in contact with dehydrating physiology longer ► Proximal liquid stool runs around hard stool and passes out of anus often without awareness

Triggers to functional constipation ► Most common is painful or frightening defecation; single event can precipitate (i.e. like PTSD) ► Age differences  Toddlers ► Dietary changes (Cow’s milk) lead to dry hard stools w/ fissures and pain ► Toilet training can lead to excessive parental pressure, anxiety, exertion of own will  Older children ► Unpleasant toilet facilities away from home ► Sexual abuse ► All stool holding behaviors lead to further dehydration of stool and a vicious cycle of painful defecation and stooling avoidance

Constipation in the ED ► Infant  straining patterns ► Toddlers  hard stools, blood on stool (fissures) ► Older children  abdominal pain  often unaware they are constipated

Emergency Department Eval ► History  Onset of sxs  Growth pattern  Presence of blood  Consistency and caliber of stools  Vomiting  Recurrent abdominal pain ► PE  Palpable mass in lower abd  Observe anus location and local pathology  Neurologic eval with anal wink, cremasteric reflex and DTRs in Les  Digital Rectal Exam (Sensitivity 88.6%/Specificity 41.6%)

Emergency Department Eval ► Radiographs  Several studies advocate use of plain abdominal films to assess presence of stool, however, stool in the colon is physiologically normal so what does it mean? Does presence of stool = impaction?  ED Physicians do rectal exams <75% of the time and order radiographs 70% of the time.  Frequently films used to “explain” sxs as attributed to constipation (i.e. appy explained away as constipation)  “conflicting evidence for an association between clinical symptoms of constipation and fecal loading of radiographs in children. Use of films cannot be supported.” Reuchlin-Vroklage, et al Arch Pediatr Adolesc Med 2005; 159

Treatment ► Infants- Infant Dyschezia  Mostly reassurance  Osmotic agents to soften stools ► Prune juice/Malt soup extract/Corn syrup  Glycerin suppositories for immediate evacuation (Avoid Use of Enemas in children under 2yo) ► Toddlers-Functional Constipation  Avoid focus on toilet training  Osmotic agents to soften stools and allow healing of fissures

Treatment ► Older children- Functional Fecal Retention  Two step procedure ► Immediate disimpaction (3-5 days)  Oral or rectal routes ► Maintenance (6-12 months)  Oral routes ► Typically mineral oil or polyethylene glycol

DosageRisks Osmotic agents- Mag/Lactulose/SorbitolVaries Cramps/flatulence/Mag intoxication Lubricants- Mineral oil Disimpaction cc/yr of life daily Maintenance 1-3cc/kg/d Lipoid pneumonitis/ Fat soluble Vit not malabsorbed Stimulants-Senna/BisacoylVaries Idiosyncratic hepatitis/analgesic nephropathy/  K Fiber-Bran/Psyllium 2.5cc powder in 240cc water TID Requires water; if not enough can constipate Osmotic enema- Phosphate enemas (Do not use in infants or neurologically impaired) 6cc/kg Trauma/bacterial translocation/electolyte shifts (  Phos/  Ca) Lavage-PEG Disimpaction 25cc/kg/hr Maintenance 5-10cc/kg/d Or 0.78gm/kg/d Cramps/vomiting/pneumonitis

Enemas-A good and a bad idea ► Magnesium enemas (also PO)  Acute mag toxicity  Ca/  Phos  Coma and Cardiac conduction defects, as well as, shock from fluid shifts ► Phosphate enemas  Electrolyte disturbances and fluid shifts ► Soap suds enemas  Bowel wall necrosis and perforation ► Tap water enemas  Water intoxication/hypervolemia  electrolyte disturbance  seizures and death ► Milk & Molasses enemas  Fermentation  perforation  Fluid and electrolyte shifts do happen

A Medical Position Statement of the NASPGHAN ► General Rec  Thorough Hx/PE-sufficient to dx functional constipation in most cases  Stool for occult blood in all infants and children with risk factors for organic disease  Abdominal radiographs can be useful  Rectal Biopsy only reliable way to exclude Hirshsprung’s Disease

A Medical Position Statement of the NASPGHAN ► Rec for Infants  Disimpaction via glycerin suppositories; avoid enemas  Osmotic and stimulant agents can be used  Avoid mineral oil  PEG has been shown to be safe in infants in a small limited trial

A Medical Position Statement of the NASPGHAN ► Rec for children  Disimpaction via oral or rectal routes okay  Balanced diet with fiber containing foods  Medications in conjunction with behavioral modification decreases time to remission  PEG is effective for acute disimpaction and maintenance therapy and is the best tolerated of all regimens

Hiddie Ho