6. Constipation Flashcards
What are the key questions when asking about constipation?
Painful, hard, uncomfortable stool
Change of stools, (occurs around toilet training age)
What are the presenting symptoms of constipation?
Poor appetite Irritable Lack of energy Abdo pain or distension Withholding or straining Pale, thin, dark things under eyes Miserable and uncomfortable Diarrhoea
Why do children become constipated?
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)
What medications make you constipated?
Gaviscon
Opiates
What is the VICIOUS STOOL CYCLE!
Holding stools (Faecel holding)
Larger and harder stool
Painful bowel movement
What is a MEGA RECTUM?
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
How do you treat chronic constipation in toddlers?
Explain the cycle of stool
Make sure hard stools don’t occur
Re-train the bowel to recognise hard stool
Remove the impaction
How do you best convey the message of constipation to the parents?
Explain situation
The child is not the blame
Draw a picture explains the passage of the intestines
Explain the MEGA RECTUM
How do you treat the impaction?
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
How can you dietally treat constipation?
Increase fibre Increase fruit Increase vegetables Increase fluids Decrease milk
What are the psychological treatments of constipation?
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
What is the poo calendar?
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
What laxatives are available to treat constipation?
Osmotic laxatives (lactukose or movicol /laxido)
Stimulant laxatives (senna, picosulphate)
Hard to get kids to take this,
What is pancolitis?
Inflammation of the entire colon, common in 60-80% of children’s UC disease
How is Crohn’s disease in children different to adults?
A lot of kids have pan-enteric disease, this means the upper GI tract is affected in around half of kids
How does ulcerative colitis present in children?
Diarrhoea and bleeding for over 2 weeks (stool cultures negative)
Abdo pain
Less systemic symptoms (fever, weight loss, growth failure, arthritis)
How does Crohns present in children?
Abdo pain
Weight loss
Growth failure
Some systemic symptoms, less often diarrhoea
What are you looking for in history and examination when looking at diarrhoea?
Intestinal symptoms Extra- intestinal manifestations (joint pain, painful, red eyes, erythema nodosum, sore bottom) Exclude infection FH Growth and sexual development Nutritional stays
What lab investigations would you do for IBD
Faecal calpotectin- if low essentially rules out IBD
FBC &ESR- anemia, thrombocytosis, raised ESR
Raised CRP, low albumin
Cultures to rule out infection
What definitive investigations can you do for IBD in children?
MRI Colonoscopy Upper GI endoscopy Mucosal biopsy Capsule endoscopy Enteroscopy
Signs of ulcerative colitis on endoscopy
Pus in the crips
White dots
Bleeds on endoscope touch
All the way round the colon
What does Crohn’s disease look like with an endoscope?
Crohn’s disease ulcers tend to be longitudinal, polycyclic ulcers (snail track)
What are the aims of treatment in IBD?
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
How do you treat Crohn’s disease in children?
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
How do you treat ulcerative colitis?
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)
