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

2. 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

3. AETIOLOGY Three broad categories Anatomic anomalies
Functional anomalies
Medical causes

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

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

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

7. 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

8. 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

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

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

11. DIAGNOSIS History Physical exam Barium enema Rectal biopsy
Anorectmanometry

12. CONSTIPATION VS HIRSCHSPRUNG’SHD
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

13. 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

14. 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 minutes, whether he passes stool or not
Gradually he will start evacuating
Minimum use of Laxatives or Purgatives
Enema may be given if necessary

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