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

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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

14. 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.

15. 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.

16. 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)

17. 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.

18. 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 WAARDENBURG SYNDROME
3- KAUFMANN-MC SYNDROME 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 MEN (TYPE 2)

19. BARIUM ENEMA EXAMINATION SHOWING RECTO-SIGMOID HIRSCHSPRUNG'S DISEASE

20. 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

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

22. 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.

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

24. 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

25. THANK YOU