6. Constipation

Question 1

What are the key questions when asking about constipation?

Answer 1

Painful, hard, uncomfortable stool

Change of stools, (occurs around toilet training age)

Question 2

What are the presenting symptoms of constipation?

Answer 2

Poor appetite
Irritable
Lack of energy
Abdo pain or distension
Withholding or straining 
Pale, thin, dark things under eyes
Miserable and uncomfortable 
Diarrhoea

Question 3

Why do children become constipated?

Answer 3

Poor diet, Insuffucient fluids
Excessive milk 
After a holiday
Potty training/school toilet (holding onto stool, doesn’t want to go)
Inter current illness/medication
FH (don’t go often)
Psychological (secondary) (?abuse)
Organic (hypothyroidism)

Question 4

What medications make you constipated?

Answer 4

Gaviscon

Opiates

Question 5

What is the VICIOUS STOOL CYCLE!

Answer 5

Holding stools (Faecel holding)
Larger and harder stool
Painful bowel movement

Question 6

What is a MEGA RECTUM?

Answer 6

Excessive stretching of the back passage. If they’ve held onto stool then passage will be stretched and feacel stretch reflex won’t kick in

Question 7

How do you treat chronic constipation in toddlers?

Answer 7

Explain the cycle of stool

Make sure hard stools don’t occur

Re-train the bowel to recognise hard stool

Remove the impaction

Question 8

How do you best convey the message of constipation to the parents?

Answer 8

Explain situation

The child is not the blame

Draw a picture explains the passage of the intestines

Explain the MEGA RECTUM

Question 9

How do you treat the impaction?

Answer 9

Increasing molikov over days

This destroys the mega rectum and emptied the colon

Is pretty horrible over the next 2-3 days

Enemas aren’t typically given

Question 10

How can you dietally treat constipation?

Answer 10

Increase fibre
Increase fruit
Increase vegetables
Increase fluids
Decrease milk

Question 11

What are the psychological treatments of constipation?

Answer 11

Make going to the toilet a pleasant experience
(Correct height, not cold, school toilets)

Soften stool and remove pain!

Avoid punitive behaviour

Reward good behaviour and retraining of the bowel

Question 12

What is the poo calendar?

Answer 12

We all have a natural reflex where after a meal we try to go to the bathroom

Create a star chart of how often they do a poo. One time for after breakfast, lunch and dinner. Small star for trying, big star for getting there. Reward for a certain amount of stars

Question 13

What laxatives are available to treat constipation?

Answer 13

Osmotic laxatives (lactukose or movicol /laxido)

Stimulant laxatives (senna, picosulphate)

Hard to get kids to take this,

Question 14

What is pancolitis?

Answer 14

Inflammation of the entire colon, common in 60-80% of children’s UC disease

Question 15

How is Crohn’s disease in children different to adults?

Answer 15

A lot of kids have pan-enteric disease, this means the upper GI tract is affected in around half of kids

Question 16

How does ulcerative colitis present in children?

Answer 16

Diarrhoea and bleeding for over 2 weeks (stool cultures negative)
Abdo pain
Less systemic symptoms (fever, weight loss, growth failure, arthritis)

Question 17

How does Crohns present in children?

Answer 17

Abdo pain
Weight loss
Growth failure
Some systemic symptoms, less often diarrhoea

Question 18

What are you looking for in history and examination when looking at diarrhoea?

Answer 18

Intestinal symptoms
Extra- intestinal manifestations (joint pain, painful, red eyes, erythema nodosum, sore bottom)
Exclude infection 
FH
Growth and sexual development
Nutritional stays

Question 19

What lab investigations would you do for IBD

Answer 19

Faecal calpotectin- if low essentially rules out IBD
FBC &ESR- anemia, thrombocytosis, raised ESR
Raised CRP, low albumin
Cultures to rule out infection

Question 20

What definitive investigations can you do for IBD in children?

Answer 20

MRI
Colonoscopy
Upper GI endoscopy
Mucosal biopsy
Capsule endoscopy
Enteroscopy

Question 21

Signs of ulcerative colitis on endoscopy

Answer 21

Pus in the crips
White dots
Bleeds on endoscope touch
All the way round the colon

Question 22

What does Crohn’s disease look like with an endoscope?

Answer 22

Crohn’s disease ulcers tend to be longitudinal, polycyclic ulcers (snail track)

Question 23

What are the aims of treatment in IBD?

Answer 23

Induce and maintain remission
Correct nutritional deficiencies (folate)
Maintain normal growth and development (settle inflammation down sufficiently)
Promote quality of life and normal psycho-social development

Question 24

How do you treat Crohn’s disease in children?

Answer 24

Nutritional therapy- induce remission, first line
Steroids- induced remission, second line (side effects poor in teenagers)

Thiopurines- maintains remission

Anti-TNF- step up therapy

Surgery for complications, doesn’t cure

Question 25

How do you treat ulcerative colitis?

Answer 25

5-ASA- 1st line induces remisison (only works if mild)
Steroids- 2nd line indices remission (side effects poor in teenagers)

5-ASA- 1st line maintain remission (aspirin and a carrier reduces inflammation in the colon)
Thiopurines- 2nd line maintain remission

Anti-TNF- step up therapy

Surgery- for failure to respond to medical therapy (curative)