Constipation

Question 1

What social problems can cause constipation?

Answer 1

Diet e.g. low fluid, fibre or excess milk

Potty training difficulties

Question 2

What physical things could cause constipation?

Answer 2

Meds e.g. Gaviscon or anti-spasmodics
Intercurrent Illness
Anatomical Abnormalities

Question 3

Most chronically constipated kids don’t have a physical cause, instead they get into a difficult cycle

Answer 3

First they get an episode of constipation
This leads to a large hard stool which causes pain or a fissure
The kid learns to withhold stool to avoid the pain which leads to further constipation etc etc

Question 4

Other than not shitting, how would a chronically constipated kid present?

Answer 4

• poor Appetite
• Irritable
• Lacking energy
• Abdo pain/distension
• Withholding or straining
• Diarrhoea (vs liquid overflowing incontinence)

look miserable, dark circles under eyes etc

Question 5

How would we go about managing a chronically constipated child?

Answer 5

Explain to parents. With diet (more fibre, fruit, veg an fluids + less milk)

Reward good behaviour with praise & star charts
Reduce adverse factors - make going to toilet a pleasant experience = e.g. school toilets, correct height, not cold, soften stool and remove pain and punitive reactions from parents

Laxatives

Question 6

What are the types of laxatives?

Answer 6

they soften stool and stim defecation:
(most important thing in treatment = soften the stool)
Could be simple like more fluids or fruit juice etc and could also use laxatives

Always better to overdo it eg really sloppy than get back to right consistency

Osmotic e.g. Lactulose
Stimulant e.g. Senna, picosulfate
Isotonic e.g. Movicol/Laxido

Question 7

What can we do if we suspect impaction?

Answer 7

That’s the only time we’d do a DRE and maybe a Stool marker X-ray study

Empty impacted rectum
Empty the colon with laxatives
maintain regular stool passage
slow weaning of treatment
ensure compliance (see child regularly)

diff ways of doing this = stimulant laxatives, enemas, manual evacuation

Question 8

What other complication can occur from chronic constipation?

Answer 8

UTI due to mass of stool causing urinary stasis

Question 9

What is normal stool frequency?

Answer 9

4 per day to 1 per week
depends on age and diet

• infants open bowels more frequently
• breast fed babies open bowels more than formula ed babies due to non-digestable polysacchardies which loosen their stools
• vegetearian who eats lots roughage also opens bowwels more frequently than a child with a poorer diet

Question 10

What is constipation?

Answer 10

difficulty passing stool and hard and painful

Question 11

What is a useful tool to use when getting someone to explain the appearance of their poo?

Answer 11

Bristol stool chart

Question 12

Wy do kids become constipated?

Answer 12

Social:
-poor diet
= Insufficient fluids, Excessive milk
(dehydrated => stools harder)
-potty training / school toilet

Physical

• intercurrent illness
• Medication eg Gaviscon, opiates

Psychological (secondary)

Organic

Question 13

What is the vicious cycle with constipation?

Answer 13

Child has a hard stool eg due to intercurrent illness and endeed up dehydrated, poor diet etc
Children have a strong instinct if something painful, don’t do it
Longer hold onto stool firmer it gets
So get more constipated and next time they go even bigger and harder, more pain
Viscious cycle

Question 14

What laxative do we tend to choose?

Answer 14

isotonic laxatives eg Movicl/Laxido

Question 15

What is the SE of lactulose (osmotic laxative)?

Answer 15

nasty windy pain

it’s a non-digestable sugar and it can get fermented in the colon, tends to cause more gas and rot your teeth

Question 16

What is the SE of picosulfate (stimulant laxative)?

Answer 16

crampy tummy pain

Question 17

How much and how long do we give treatment for?

Answer 17

how much?
enough to make them go and to make sure stool always soft & never painful
how long?
until no longer required
related to duration of problem
(Usually say however long its been going on is however long treatment will be needed, don’t want to undertreat)

explanation and understanding is critical to success

Question 18

What is impaction?

Answer 18

A fecal impaction is a large lump of dry, hard stool that stays stuck in the rectum. It is most often seen in people who are constipated for a long time.

severe constipation

Question 19

What is megarectum and what can this lead to?

Answer 19

what happens in impaction

Children hold and hold until lose nice tangerine sized rectum until got big dilated rectum
That pushes forward largely on urethra so complications we see of constipation and a mega rectum = often children don’t empty bladder completely so at end of micturition there’s some urine left behind (more chance of infection as normally bigs crawl up into bladder and we wahs them out with peeing so more chance of UTIs if some urine left behind)
So megarectum pressing forward can even cause urinary retention

Rectum: internal and external anal sphincter
Internal = v strong muscle
Lots poo building up holds internal sphincter open
So all we have I sthe external sphincter which they squeeze to hold poo coming
But because the internal is the strong one every time the bowel gives a little squeeze then can leak stool = not doing it on purpose, the reason they are soiling isn’t being bad or due to behaviourla problems but it’s because they have a rectum full of stool holding open their internal anal sphincter