Constipation Flashcards
Causes of acute constipation
- Fluid depletion->fever, hot weather
2. Bowel obstruction->congenital, adhesions
Signs a child may be constipated
Infrequent stools Pain and straining on defecation Abdominal pain Passsing small hard stools Avoiding the toilet Not having an urge to defecate Difficulty finishing defecation Painful bottom Dribbling urine Fecal smell Leaking liquid stools into underwear
Chronic causes of constipation
- Functional->common, disabled children, witholding from painful, +risk megacolon. Use laxatives, bowel training and diet.
- Hirschsprung’s->newborn, FTT, abdominal distension. Requires rectal biopsy.
Important history
Infrequent but normal stools not indicator of constipation
Hardness
Pain
Abdominal pain
Blood, anal fissure
Onset- ?infancy
Precipitating events-> mismanaged toilet training, fluid depletion, febrile illness, vomiting
Hiding while defecating, withholding behaviour
Diet
Consider maltreatment
Time of meconium passage
Examination
Growth ht/wt/HC->Hirchsprungs and FTT Abdominal examination->hard stool in LLQ Anorectal examination->rectal not usually indicated. ?Anal fissure. Spine->deep sacral cleft or tuft of hair Neurology->assessment of lower limb
Investigations
AXR not generally indicated
Rectal biopsy->hirschsprungs
Growth faltering->check celiac screen and hypothyroidism
What is fecal impaction
When no adequate bowel movement for days/weeks->a large fecal mass becomes compacted in the rectum
If Hirschsprung’s disease more common in boys or girls
More common in boys
Risk factors for constipation
Diet->low fluid, low fibre Holding of stools Change in routine Lack of exercise Genetics Medication->codeine, cough, anticonvulsants, antihistamines
Management of constipation: overview
Stage 1: Dietary management and behaviour modifications
Stage 2: Disimpaction
Stage 3: Maintenance
Stage 4: Vigilance
How frequently do children pass stools
May pass every 2-3 days, breast fed may be less frequently
When is constipation particularly common
When transitioning to solids, toilet training,
Most common cause of constipation in childhood
Functional
Pain->apprehension->retention->passage of hard stools->cycle of withholding
Less common Medical causes
Cow milk allergy
Celiac disease
Hypercalcemia
Hypothyroidism
Less common surgical causes
Hirschsprung
Meconium ileus
Anatomic malformations of anus
Spinal nord abnormalities
Behaviour modifications
Position- foot stool, knees higher than hips. Lean forward, elbows on knees
Toilet sits->5 minutes three times a day, after meals. Time. Encourage child to bulge abdomen/ Praise child for sitting on the toilet.
Chart or diary
Avoid toilet training until child is passing soft, painless stools
Dietary management
Fibre->wholewheat bread and cereals
Fluids
Stool softeners->fruit (with peel), vegetables, beans, nuts, prune juice
Disimpaction (1-2 weeks or until symptoms resolve)
1) Laxatives Iso-osmotic->Movicol= +fluid, softens Stimulant laxative->sodium picosulfate, bisacodyl, senna if Movicol ineffective Osmotic laxatives->lactulose Bulking agent->Fybogel 2)Glycerin suppositories 3)Enemas may rarely be used in severe 4)Manual evacuation under general anaesthesia in extreme cases
Maintenance therapy
Stools should be kept soft with softener and stimulant for 6 months.
Continue with dietary and behaviour modifications
Vigilance
Start or escalate treatment at first indication of recurrence of hard stools