Chronic Constipation

Question 1

Questions to ask in history of constipation

Answer 1

How often?
How hard?
Painful?
Has there been a change?
Bristol stool chart

Question 2

What frequency of defaecation is normal in children?

Answer 2

Range from 4 per day to 1 per week
Depends on age - younger children generally more frequent
Depends on diet

Question 3

Signs and symptoms of chronic constipation

Answer 3

Poor appetite
Lack of energy 
Irritable 
Abdominal pain or distension 
Withholding or straining 
Diarrhoea

Question 4

Causes of chronic constipation

Answer 4

Social

• poor diet e.g. insufficient fluids, excessive milk
• potty training/school toilets

Physical

• intercurrent illness
• medication

Family history

Psychological

Organic (rare)

Question 5

Dietary treatment of chronic constipation

Answer 5

Increase fibre
Increase fruit
Increase vegetables
Increase fluids
Decrease milk

Question 6

Treatment of chronic constipation to reduce aversive factors

Answer 6

Make going to the toilet a normal experience

• correct height
• not cold
• school toilets

Soften stool and remove pain

Avoid punitive behaviour from parents

Question 7

How to reward good behaviour in treatment of chronic constipation

Answer 7

General praise

Star charts

Question 8

Treatment of chronic constipation to soften stool and stimulate defaecation

Answer 8

Osmotic laxatives e.g. lactulose
Stimulant laxatives e.g. Senna, picolax, generally avoided as can cause abdominal pain
Isotonic laxatives e.g. movicol

Question 9

Advantages and disadvantages of laxative treatment of chronic constipation

Answer 9

Advantages

• non-invasive
• given by parents at home

Disadvantages

• non-compliance
• side effects

Question 10

Treatment of impaction

Answer 10

Happens due to long period of constipation
Incontinence and diarrhoea

Empty impacted rectum - may need to use very high dose laxatives
Empty colon
Maintain regular stool passage
Slow weaning off of treatment

Question 11

Features of chronic constipation management

Answer 11

Treat early and effectively
Recognise impaction
Choose most patient-friendly treatment
Almost all stages of diagnosis and treatment can be done safely and effectively in the community

Question 12

Presenting features of Crohn’s disease

Answer 12

Can affect anywhere in GI tract 
Diarrhoea 
Rectal bleeding 
Abdominal pain 
Fever
Weight loss 
Growth failure 
Arthritis 
Mass

Question 13

Presenting features of Ulcerative colitis

Answer 13

Only affects colon 
Diarrhoea 
Rectal bleeding
Abdominal pain 
Fever
Weight loss
Growth failure 
Arthritis

Question 14

Important features of history and examination of a child with IBD

Answer 14

Intestinal symptoms 
Extra-intestinal manifestations 
Exclude infection e.g. campylobacter
Family history 
Growth and sexual development 
Nutritional status

Question 15

Lab investigations of IBD

Answer 15

FBC and ESR

• anaemia
• thrombocytosis
• raised ESR

Biochemistry

• stool calprotectin
• raised CRP
• low albumin

Microbiology
- no stool pathogens

Question 16

Definitive investigations for IBD

Answer 16

Radiology

• especially Crohn’s disease
• MRI
• barium meal and follow through

Endoscopy

• colonoscopy
• upper GI endoscopy
• mucosal biopsy
• capsule endoscopy
• enteroscopy

Question 17

Aims of treatment of IBD

Answer 17

Induce and maintain remission
Correct nutritional deficiencies
Maintain normal growth and development

Question 18

Methods of treatment of IBD

Answer 18

Medical

• anti-inflammatory drugs
• immunosuppressive drugs e.g. azathioprine
• biologics e.g. infliximab

Nutritional

• often exclusive nutritional therapy used first line, strictly fluid diet for 8 weeks, oral or nasogastric depending on compliance
• immune modulation
• nutritional supplementation

Surgical

• biologics have reduced need for surgery
• may be indicated where entire bowel is chronically inflamed or quality of life of child is severely impaired