CONSTIPATION IN CHILDREN Colonel Man Mohan Harjai Associate Professor Army Hospital (Research and Referral) Delhi Cantt 110 010 INDIA

DEFINITIONS Constipation Soiling Encopresis Difficult, infrequent passage of hard stools Soiling Intermittent passage of small amount of faeces which stain the undergarments of the child Encopresis Soiling due to psychological factors and not because of any organic lesion

AETIOLOGY Three broad categories Anatomic anomalies Functional anomalies Medical causes

ANATOMIC ABNORMALITIES Neurologic malformations Spina bifida – meningomyeloceles Trauma to spinal cord Cerebral palsy Obstructive malformations Hirschsprung’s disease Anal stenosis or anterior ectopic anus

FUNCTIONAL ABNORMALITIES No evidence of anatomic disorder Occurs more often in boys

METABOLIC ABNORMALITIES History dates back to specific event Febrile illness Dietary change School going Hypothyroidism Lead poisoning

PROBLEMS DUE TO CONSTIPATION Intermittent or continuous soiling Perianal inflammatory lesions Recurrent abdominal pain Loss of appetite failure to thrive Difficulty in toilet training Emotional and social maladjustments

PATHOPHYSIOLOGY Child voluntarily constricts anal sphincters and does not evacuate his bowel  Rectal ampulla stretches and accommodates increasing amount of stool Water is mainly absorbed and stool becomes harder With passage of time rectal ampulla overstretches Overstretching reduces the urge to daefecate Stool is pushed into the anal canal also and starts collecting there leading to soiling

PRESENTING FEATURES History Difficulty in passing stools Irregular bowel movements Passage of hard stool Crampy abdominal pain Soiling Failure to thrive

CLINICAL EXAMINATION Short statured child Thin built Anemic Abdomen – protrubent Palpable faecal mass in sigmoid colon

DIAGNOSIS History Physical exam Barium enema Rectal biopsy Anorectmanometry

CONSTIPATION VS HIRSCHSPRUNG’S HD Constipation Age Since birth or within 1 to 2 months of age Starts after 1 year of age Soiling Unusual Common Straining at defecation No straining Present Ability to pass large bulky stool Pain and bleeding on defecation Anal fissures Absent Rectal exam Rectum empty Full of hard stool Barium enema Transitional zone Dilatation from anal canal upwards Rectal biopsy Ganglion cells absent Ganglion cells present

MANAGEMENT Aim of treatment Can be done by Thorough cleaning of rectum Decompression of overstretched colon and rectum Can be done by Repeated oil and saline enema Manual evacuation, if necessary

MANAGEMENT Multimodal approach after evacuation Toilet training Change in diet (fibre rich) Reduce quantity of milk gradually and replaced by solid food Stool softeners may be used Toilet training Child should be made to sit on toilet seat in the morning for at least 10 - 15 minutes, whether he passes stool or not Gradually he will start evacuating Minimum use of Laxatives or Purgatives Enema may be given if necessary

RESULTS Toilet training programme regains tone of rectal ampulla and sphincters Usually the child becomes normal in 1 - 2 months The programme has to be continued till such time child develops normal reflexes to evacuate bowels