Constipation Flashcards
How is constipation defined in the pediatric population?
Constipation is defined as abnormally delayed or infrequent passage of stool.
What are the two main types of constipation in children?
- Functional (idiopathic) constipation - No underlying medical or anatomical problem.
- Organic constipation - Secondary to an underlying medical or anatomical issue.
What criteria are used to diagnose functional constipation?
The Rome Criteria are used to diagnose functional constipation.
How long must symptoms be present to meet the Rome Criteria for functional constipation in children?
1 month in children under 4 years.
• 2 months in children over 4 years.
What are the diagnostic criteria for functional constipation according to the Rome Criteria? (Name at least 4)
At least 2 or more of the following:
1. 2 or fewer stools per week.
2. 1 or more episodes of incontinence per week (after toilet training).
3. History of excessive stool retention.
4. History of hard or painful bowel movements.
5. Presence of large faeculoma in the rectum (clinically or on X-ray).
6. History of passing large diameter stools (that may even obstruct the toilet).
What is necessary to determine the presence of a predisposing condition for constipation?
A combination of history, clinical examination, and special investigations.
How do breastfed babies’ stooling patterns typically vary?
Breastfed babies have highly variable stooling patterns. They may stool several times a day or as seldom as once a week.
What should be observed in neonates who appear to be “grunting” or “squirming”?
This behavior is often normal and does not necessarily indicate pathology. It is common for small babies to make faces, squirm, or grunt when asleep or awake. As long as the baby is growing well and otherwise healthy, no intervention is needed.
What should be checked when assessing a neonate for constipation?
- Confirm the anus is normal size and in the center of the pigmented area, indicating the muscle complex.
- Check for signs of Hirschsprung’s disease.
- Look for evidence of occult spinal dysraphism.
What are the indications for referral to work-up for possible Hirschsprung’s disease in neonates and young infants? (List at least 3)
- Delayed passage of meconium (greater than 48 hours in term infants).
- Constipation from the first few weeks of life.
- Chronic abdominal distension plus vomiting.
- Family history of Hirschsprung’s disease.
- Faltering growth in addition to any of the above.
How can spinal defects lead to constipation?
Spinal defects, such as Myeomeningocele, tethered cord, fatty filum, sacral agenesis, and other overt, occult, or acquired defects, can cause significant constipation due to impaired nerve function affecting bowel motility.
What is essential for managing constipation in patients with spinal defects?
Patients with spinal defects require active, lifelong management of their constipation and should be referred to a relevant specialty for long-term management and follow-up.
What is African degenerative leiomyopathy, and where is it most commonly seen?
African degenerative leiomyopathy is a condition commonly seen in children from South, East, and Central Africa, especially in the Eastern Cape of South Africa.
What is the typical presentation of African degenerative leiomyopathy?
The typical presentation includes:
1. Long history of abdominal distension, cramps, and vomiting.
2. Constipation.
3. Faltering growth.
4. Malabsorption.
What radiological findings are seen in African degenerative leiomyopathy?
X-rays show marked gaseous distension, particularly of the colon (megacolon).
What histological findings are associated with African degenerative leiomyopathy?
Histology of the bowel shows:
1. Smooth muscle degeneration.
2. Vacuolated cytoplasm.
3. Increased fibrosis of muscular layers.
4. Normal innervation, but in some cases, hyperplasia of the myenteric plexus.
What is the prognosis for African degenerative leiomyopathy?
It is a progressive, life-limiting condition, requiring specialist management.
What are common symptoms of peri-anal fissures in children?
Common symptoms include severe pain on defecation and bloody streaks on stool and on wiping.
When should a child with peri-anal fissures be referred for further investigation?
Referral is necessary if the fissures are non-healing, recurrent, or associated with peri-anal sepsis and ulceration.
How should most peri-anal fissures be managed in children?
Most peri-anal fissures can be managed with:
1. Stool softeners.
2. Isosorbide mononitrate paste applied to the anus.
3. Anaesthetic cream.
What is the purpose of taking a detailed history in a child with constipation?
The purpose is to:
1. Identify any underlying conditions predisposing to constipation.
2. Determine if the child meets the criteria for functional constipation.
3. Assess if the child’s diet could be contributing to constipation.
What underlying conditions should be considered when taking the history of a child with constipation?
Conditions to consider include:
1. Cerebral palsy or other central nervous system abnormalities.
2. Inherited and genetic abnormalities (e.g., Trisomy 21, cystic fibrosis).
3. Spinal defects (e.g., myelomeningocele, tethered cord, sacral agenesis, previous pelvic or spinal surgery, traumatic spinal cord injury).
4. Autism.
5. Hypothyroidism.
6. Any anorectal disorders (e.g., imperforate anus, Hirschsprung’s disease).
How can a patient’s diet contribute to constipation?
A poor diet frequently plays a significant role in functional constipation. Taking a detailed account of the patient’s diet can help identify problem areas.
What psychosocial stressors could contribute to constipation in children?
Psychosocial stressors such as new school, bullying, family conflict, lack of clean and safe toilets at school, or medication usage (e.g., opiates, antidepressants) can contribute to constipation.
What are the red flags during history taking that should prompt further investigation for constipation?
Red flags include:
1. Delayed passage of meconium or constipation from the first weeks of life.
2. A family history of Hirschsprung’s disease.
3. Recurrent urinary tract infections.
4. History of soiling.
What is the purpose of the physical examination in a child with constipation?
The purpose is to confirm that the child has no physical findings that may indicate an underlying organic cause for constipation.
What are the red flags during examination that should prompt referral or further investigation for constipation?
Red flags include:
1. Acute illness with symptoms like vomiting, abdominal distension, peritonism, dehydration, or sepsis.
2. Chronic abdominal distension with episodes of vomiting.
3. A child with malnutrition or failure to thrive.
4. Evidence of occult spinal defects.
5. Evidence of anorectal malformations.
What components are included in the physical examination of a child with constipation?
A thorough physical examination should include:
1. General examination (nutritional status, behavior).
2. Abdominal examination (assess for distension and masses).
3. Lower back assessment (check for evidence of spinal dysraphisms such as dimples, sinuses, masses, naevi, tufts of hair, or asymmetry).
4. Perineal area examination (ensure anus is of expected size and site, check for skin tags, fissures, active or previous peri-anal fistulas or abscesses)
What is the purpose of special investigations in paediatric constipation?
The purpose is to aid in diagnosing organic causes of constipation.
What are the first-line investigations to consider in paediatric constipation?
First-line investigations include:
1. Thyroid Stimulating Hormone (TSH) to exclude hypothyroidism.
2. Haemoglobin level and MCV to exclude iron-deficiency anaemia.
What are second-line investigations for constipation in children?
Second-line investigations include:
1. Abdominal X-ray (to check for gas-bloating, soiling, vomiting).
2. Spinal and sacral imaging (if occult spinal dysraphism is suspected - start with X-ray and proceed to MRI if needed).
3. Renal and bladder ultrasound (for patients with occult spinal dysraphism or a history of urinary tract infection).
What are tertiary investigations for constipation, and when are they conducted?
Tertiary investigations are conducted at a specialist facility and include:
1. Rectal biopsy to exclude Hirschsprung’s disease.
2. Contrast enema.
What are the goals of managing paediatric constipation?
The goals are:
1. To empty the colon of impacted stool.
2. To maintain regular, soft bowel movements.
3. To manage patient and caregiver expectations regarding therapy duration, recurrence, and long-term prognosis.
What is the approach to acute treatment in managing impacted stool in paediatric constipation?
Acute treatment aims to empty the colon and includes:
1. Paediatric phosphate enemas (e.g., Fleet) daily for 2–3 days to evacuate the rectal plug.
2. Polyethylene glycol (Go-Lytely) orally or via naso-gastric tube at 10–30 ml/kg/hour for 6–8 hours, repeated if necessary.
3. Manual disimpaction if the above measures fail.
When managing acute constipation, what should be monitored during treatment?
Serum electrolytes must be monitored during the process to avoid imbalances.
What is the role of dietary advice in the management of paediatric constipation?
Dietary advice is mandatory in managing constipation, and a dietician’s help should be sought to ensure proper nutrition that promotes regular bowel movements.
What are the components of behavioural modification in managing paediatric constipation?
Behavioural modification includes:
1. Allowing adequate time for stooling (20–30 minutes), preferably after breakfast.
2. Parental education on avoiding withholding behaviours.
3. Avoiding scolding; using ‘star’ or ‘reward’ charts.
4. Encouraging regular exercise to promote bowel movement.
What medications are typically used for maintenance therapy in paediatric constipation?
Medications for children over 2 years old:
1. Stool softeners (e.g., Sorbitol or Lactulose).
2. Stimulant laxatives (e.g., Senokot).
3. If response is poor after 2–3 months, bisacodyl may be added.
What additional treatments might be needed for children with peri-anal fissures during maintenance therapy?
Adjuvant therapies for fissures, such as Isosorbide mononitrate paste, may be required to help with healing.
What monitoring is necessary for children on long-term Senokot for constipation?
Children on long-term Senokot should have bi-annual liver function tests due to the potential risk of hepatic dysfunction.
How long is maintenance therapy for paediatric constipation typically required?
Treatment needs to be ongoing for months to years, allowing time for the megarectum to return to its normal size and motility.
What is the Bristol Stool Chart used for?
The Bristol Stool Chart is used to classify and describe the form of stools, helping to assess bowel health and identify potential gastrointestinal issues.
How many types of stool are described in the Bristol Stool Chart?
The Bristol Stool Chart describes seven types of stool, ranging from hard, lumpy stools to liquid diarrhea.
What does Type 1 stool on the Bristol Stool Chart look like?
Type 1 stool is separate hard lumps, like nuts, and is difficult to pass. It suggests severe constipation.
What does Type 2 stool on the Bristol Stool Chart look like?
Type 2 stool is sausage-shaped but lumpy, indicating mild constipation.
What does Type 3 stool on the Bristol Stool Chart look like?
Type 3 stool is sausage-shaped with cracks on the surface, which is considered a normal stool with slightly slower transit time.
What does Type 4 stool on the Bristol Stool Chart look like?
Type 4 stool is like a sausage or snake, smooth and soft, considered ideal and indicates healthy bowel function.
What does Type 5 stool on the Bristol Stool Chart look like?
Type 5 stool is soft blobs with clear-cut edges, indicating lack of fiber or mild diarrhea. It is a sign of normal bowel function but may need dietary adjustment
What does Type 6 stool on the Bristol Stool Chart look like?
Type 6 stool is fluffy pieces with ragged edges, indicating mild diarrhea and often suggests too much fiber or stress.
What does Type 7 stool on the Bristol Stool Chart look like?
Type 7 stool is watery, no solid pieces, and is classified as diarrhea, indicating possible infection, gastrointestinal disturbance, or other underlying conditions.
How is the Bristol Stool Chart helpful in diagnosing constipation or diarrhea?
The Bristol Stool Chart helps assess stool consistency, which provides insight into whether the bowel movements are normal or indicate a potential issue such as constipation (Type 1-2) or diarrhea (Type 6-7).
