BY DR.RANDA AL-GHANEM PEDIATRIC GI CONSULTANT Constipation BY DR.RANDA AL-GHANEM PEDIATRIC GI CONSULTANT

DEFINITION INFREQUENT BOWEL MOVEMENTS (TYPICALLY THREE TIMES OR FEWER PER WEEK) DIFFICULTY DURING DEFECATION (STRAINING DURING MORE THAN 25% OF BOWEL MOVEMENTS OR A SUBJECTIVE SENSATION OF HARD STOOLS), OR THE SENSATION OF INCOMPLETE BOWEL EVACUATION.

CONSTIPATION IN CHILDREN USUALLY OCCURS AT THREE DISTINCT POINTS IN TIME: AFTER STARTING FORMULA OR PROCESSED FOODS (WHILE AN INFANT), DURING TOILET TRAINING IN TODDLERHOOD, AND SOON AFTER STARTING SCHOOL. AFTER BIRTH, MOST INFANTS PASS 4-5 SOFT LIQUID BOWEL MOVEMENTS (BM) A DAY.  BREAST-FED INFANTS USUALLY TEND TO HAVE MORE BM COMPARED TO FORMULA-FED INFANTS.

SOME BREAST-FED INFANTS HAVE A BM AFTER EACH FEED, WHEREAS OTHERS HAVE ONLY ONE BM EVERY 2–3 DAYS. INFANTS WHO ARE BREAST-FED RARELY DEVELOP CONSTIPATION.  BY THE AGE OF TWO YEARS, A CHILD WILL USUALLY HAVE 1–2 BOWEL MOVEMENTS PER DAY AND BY FOUR YEARS OF AGE, A CHILD WILL HAVE ONE BOWEL MOVEMENT PER DAY.

CAUSES THE CAUSES OF CONSTIPATION CAN BE DIVIDED INTO CONGENITAL, PRIMARY, AND SECONDARY. THE MOST COMMON CAUSE IS PRIMARY AND NOT LIFE- THREATENING.  IN THE ELDERLY, CAUSES INCLUDE: INSUFFICIENT DIETARY FIBER INTAKE, INADEQUATE FLUID INTAKE, DECREASED PHYSICAL ACTIVITY, SIDE EFFECTS OF MEDICATIONS, HYPOTHYROIDISM, AND OBSTRUCTION BY COLORECTAL CANCER. FEMALES ARE MORE OFTEN AFFECTED THAN MALES.

PRIMARY PRIMARY OR FUNCTIONAL CONSTIPATION IS ONGOING SYMPTOMS FOR GREATER THAN SIX MONTHS NOT DUE TO ANY UNDERLYING CAUSE SUCH AS MEDICATION SIDE EFFECTS OR AN UNDERLYING MEDICAL CONDITION.  IT IS NOT ASSOCIATED WITH ABDOMINAL PAIN, THUS DISTINGUISHING IT FROM IRRITABLE BOWEL SYNDROME.  IT IS THE MOST COMMON CAUSE OF CONSTIPATION.

DIET CONSTIPATION CAN BE CAUSED OR EXACERBATED BY A LOW FIBER DIET, LOW LIQUID INTAKE, OR DIETING. MEDICATION MANY MEDICATIONS HAVE CONSTIPATION AS A SIDE EFFECT. SOME INCLUDE (BUT ARE NOT LIMITED TO); OPIOIDS COMMON PAIN KILLERS , DIURETICS ,  ANTIDEPRESSANTS , ANTIHISTAMINES , ANTI PASMODICS , ANTICONVULSANTS, AND ALUMINUM ANTACIDS.

METABOLIC AND MUSCULAR METABOLIC AND ENDOCRINE PROBLEMS WHICH MAY LEAD TO CONSTIPATION INCLUDE:  HYPERCALCEMIA, HYPOTHYROIDISM, DIABETES MELLITUS,CYSTIC FIBROSIS, AND CELIAC DISEASE.  CONSTIPATION IS ALSO COMMON IN INDIVIDUALS WITH MUSCULAR AND MYOTONIC DYSTROPHY.

STRUCTURAL AND FUNCTIONAL ABNORMALITIES CONSTIPATION HAS A NUMBER OF STRUCTURAL (MECHANICAL, MORPHOLOGICAL, ANATOMICAL) CAUSES, INCLUDING: SPINAL CORD LESIONS , ANAL FISSURES, AND PROCTITIS. CONSTIPATION ALSO HAS FUNCTIONAL (NEUROLOGICAL) CAUSES, INCLUDING ANISMUS, DESCENDING PERINEUM SYNDROME, AND HIRSCHSPRUNG'S DISEASE.  IN INFANTS, HIRSCHSPRUNG'S DISEASE IS THE MOST COMMON MEDICAL DISORDER ASSOCIATED WITH CONSTIPATION. ANISMUS OCCURS IN A SMALL MINORITY OF PERSONS WITH CHRONIC CONSTIPATION OR OBSTRUCTED DEFECATION.

PSYCHOLOGICAL VOLUNTARY WITHHOLDING OF THE STOOL IS A COMMON CAUSE OF CONSTIPATION. THE CHOICE TO WITHHOLD CAN BE DUE TO FACTORS SUCH AS FEAR OF PAIN, FEAR OF PUBLIC RESTROOMS, OR LAZINESS.  WHEN A CHILD HOLDS IN THE STOOL A COMBINATION OF ENCOURAGEMENT, FLUIDS,FIBER, AND LAXATIVES MAY BE USEFUL TO OVERCOME THE PROBLEM.

DIAGNOSIS THE DIAGNOSIS IS ESSENTIALLY MADE FROM THE PATIENT'S OR PARENTS DESCRIPTION OF THE SYMPTOMS ( INCLUDE BLOATING, DISTENSION, ABDOMINAL PAIN, HEADACHES, A FEELING OF FATIGUE AND NERVOUS EXHAUSTION, OR A SENSE OF INCOMPLETE EMPTYING) AND NUTRETIONAL HISTORY. DURING PHYSICAL EXAMINATION, SCYBALA (MANUALLY PALPABLE LUMPS OF STOOL) MAY BE DETECTED ON PALPATION OF THE ABDOMEN.

DIAGNOSIS RECTAL EXAMINATION GIVES AN IMPRESSION OF THE ANAL SPHINCTER TONE AND WHETHER THE LOWER RECTUM CONTAINS ANY FECES OR NOT AND FOR POLYPS. A COLONOSCOPE AND X-RAYS OF THE ABDOMEN, GENERALLY ONLY PERFORMED IF BOWEL OBSTRUCTION IS SUSPECTED.

STRAINING WITH MORE THAN ONE-FOURTH OF DEFECATIONS CRITERIA THE ROME II CRITERIA FOR CONSTIPATION REQUIRE AT LEAST TWO OF THE FOLLOWING SYMPTOMS FOR 12 WEEKS OR MORE OVER THE PERIOD OF A YEAR: STRAINING WITH MORE THAN ONE-FOURTH OF DEFECATIONS HARD STOOL WITH MORE THAN ONE-FOURTH OF DEFECATIONS FEELING OF INCOMPLETE EVACUATION WITH MORE THAN ONE- FOURTH OF DEFECATIONS SENSATION OF ANORECTAL OBSTRUCTION WITH MORE THAN ONE- FOURTH OF DEFECATIONS MANUAL MANEUVERS TO FACILITATE MORE THAN ONE-FOURTH OF DEFECATIONS FEWER THAN THREE BOWEL MOVEMENTS PER WEEK INSUFFICIENT CRITERIA FOR IRRITABLE BOWEL SYNDROME

PREVENTION CONSTIPATION IS USUALLY EASIER TO PREVENT THAN TO TREAT. FOLLOWING THE RELIEF OF CONSTIPATION. MAINTENANCE WITH ADEQUATE EXERCISE, FLUID INTAKE, AND HIGH FIBER DIET IS RECOMMENDED.  CHILDREN BENEFIT FROM SCHEDULED TOILET BREAKS, ONCE EARLY IN THE MORNING AND 30 MINUTES AFTER MEALS.

TREATMENT THE MAIN TREATMENT OF CONSTIPATION INVOLVES THE INCREASED INTAKE OF WATER AND FIBER. THE ROUTINE USE OF LAXATIVES IS DISCOURAGED, AS HAVING BOWEL MOVEMENTS MAY COME TO BE DEPENDENT UPON THEIR USE. ENEMAS CAN BE USED TO PROVIDE A FORM OF MECHANICAL STIMULATION. HOWEVER, ENEMAS ARE GENERALLY USEFUL ONLY FOR STOOL IN THE RECTUM, NOT IN THE INTESTINAL TRACT.

LAXATIVES - LACTULOSE  AND MILK OF MAGNESIA  HAVE BEEN COMPARED WITH POLYETHYLENE GLYCOL (PEG) IN CHILDREN. - ALL HAD SIMILAR SIDE EFFECTS, BUT PEG WAS MORE EFFECTIVE AT TREATING CONSTIPATION. OSMOTIC LAXATIVES ARE RECOMMENDED OVER STIMULANT LAXATIVES. PHYSICAL INTERVENTION - CONSTIPATION THAT RESISTS THE ABOVE MEASURES MAY REQUIRE PHYSICAL INTERVENTION SUCH AS MANUAL DISIMPACTION (THE PHYSICAL REMOVAL OF IMPACTED STOOL USING THE HANDS)

PROGNOSIS - COMPLICATIONS THAT CAN ARISE FROM CONSTIPATION INCLUDE  ANAL FISSURES, RECTAL PROLAPSE, AND FECAL IMPACTION.  - STRAINING TO PASS STOOL MAY LEAD TO HEMORRHOIDS. - IN LATER STAGES OF CONSTIPATION, THE ABDOMEN MAY BECOME DISTENDED, HARD AND DIFFUSELY TENDER. SEVERE CASES ("FECAL IMPACTION" OR MALIGNANT CONSTIPATION) MAY EXHIBIT SYMPTOMS OF BOWEL OBSTRUCTION (VOMITING, VERY TENDER ABDOMEN) AND ENCOPRESIS, WHERE SOFT STOOL FROM THE SMALL INTESTINE BYPASSES THE MASS OF IMPACTED FECAL MATTER IN THE COLON.

HIRSCHSPRUNG`S DISEASE DEFINITION:- DEFECT IN ITESTINAL MOTILITY ASSOCIATED WITH COPLETE ABSENCE OF ENTERIC GANGELIA IN THE INVOLVED SEGMENT OF THE COLON. INCIDENCE: 1:5000 LIVEBIRTH RATIO: 4 MALE : 1 FEMALE ASSOCIATED WITH: 1-DOWN SYNDROME 2- WAARDENBURG SYNDROME 3- KAUFMANN-MC SYNDROME 4- SMITH LEMLI OPTIZ SYNDROME 5- GOLDBERG SHPRINZEN SYNDROME 6- ONDINE SYNDROME 7- V-U REFLUX AND HYDROURETERS DIVERTICULUMN OF BLADDER 8-CEREBRAL A-V MALFORMATION 9- MICROCEPHALY 10- MYELOMENINGOCELE 11- MEN (TYPE 2)

BARIUM ENEMA EXAMINATION SHOWING RECTO-SIGMOID HIRSCHSPRUNG'S DISEASE

CLINICAL FINDING: 2/3 OF CASES DIAGNOSED AT 3 MONTHS VERY SMALL NUMBERS OF PATIENT DIAGNOSED AFTER 5 YEARS 1ST WEEK OF LIFE: PATIENT IS AVERAGE OF WEIGHT. FAIL TO PASS MECONIUM RELUCTANT TO FEED BILIOUS VOMITING ABDOMINAL DISTENSION GRUNTING

INFANCY: PRESENT WITH : CONSTIPATION ABDOMINAL DISTENSION VOMITING CHILDHOOD: PRESENT WITH CONSTIPATION OFFENSIVE RIBBON-LIKE STOOL HYPOCHROMIC ANEMIA HYPOPROTEINEMIA ENCOPORESIS

DIAGNOSIS: RECTAL EXAM: NARROW, EMPTY RECTUM AND AS THE FINGER IS WITHDRAWN. X-RAY:DESTENSION OF GAS AND ABSENCE OF GAS IN PELVIS RECTAL BIOPSY: PROCEDURE OF CHOISE. MANOMETRIC STUDY: RECORDING INTERNAL AND EXTERNAL RECTAL PRESSURE.

TREATMENT:- CORRECT DEHYDRATION. CORRECT ACID-BASE PROBLEMS PARENTERAL FLUIDS CORRECT HYPOALBUMINEMIA OR ANY SHOCK RECTAL IRRIGATION BY NORMAL SALINE SOLUTION SURGERY:COLOSTOMY.

FUNCTIONAL CONSTIPATION DEFFERENTIATE BETWEEN FUNCTIONAL CONSTIPATION AND HIRSCHSPRUNG FUNCTIONAL CONSTIPATION HIRSCHSPRUNG DISEASE HISTORY AFTER 2 YEARS AT BIRTH ENCOPRESIS COMMON VERY RARE F.T.T UNCOMMON POSSIBLE ENTEROCOLITIS NONE ABDOMINAL PAIN EXAMINATION ABDOMINAL DISTENSION RARE POOR WEIGHT GAIN ANAL TONE NORMAL RECTAL EXAM STOOL IN AMPULA AMPULA EMPTY LAB ANORECTAL MANOMETRY DISTENSION OF THE RECTUM CAUSES RELAXATION OF UNIT SPHINCTER NO SPHINCTER OR PARADOXIAL RELAXATION OR INCREASE IN PRESSURE RECTAL BIOPSY NO GANGELIA CELL BA ENEMA MASSIVE AMOUNT OF STOOL NO TRANSITIONAL ZONE INCREASE ACETYL CHOLENSTRASE STAINING TRANSITION ZONE, DELAYED EVACUATION

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