Constipation

Question 1

Causes of acute constipation

Answer 1

1. Fluid depletion->fever, hot weather

2. Bowel obstruction->congenital, adhesions

Question 2

Signs a child may be constipated

Answer 2

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

Question 3

Chronic causes of constipation

Answer 3

1. Functional->common, disabled children, witholding from painful, +risk megacolon. Use laxatives, bowel training and diet.
2. Hirschsprung’s->newborn, FTT, abdominal distension. Requires rectal biopsy.

Question 4

Important history

Answer 4

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

Question 5

Examination

Answer 5

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

Question 6

Investigations

Answer 6

AXR not generally indicated
Rectal biopsy->hirschsprungs
Growth faltering->check celiac screen and hypothyroidism

Question 7

What is fecal impaction

Answer 7

When no adequate bowel movement for days/weeks->a large fecal mass becomes compacted in the rectum

Question 8

If Hirschsprung’s disease more common in boys or girls

Answer 8

More common in boys

Question 9

Risk factors for constipation

Answer 9

Diet->low fluid, low fibre
Holding of stools
Change in routine
Lack of exercise
Genetics
Medication->codeine, cough, anticonvulsants, antihistamines

Question 10

Management of constipation: overview

Answer 10

Stage 1: Dietary management and behaviour modifications
Stage 2: Disimpaction
Stage 3: Maintenance
Stage 4: Vigilance

Question 11

How frequently do children pass stools

Answer 11

May pass every 2-3 days, breast fed may be less frequently

Question 12

When is constipation particularly common

Answer 12

When transitioning to solids, toilet training,

Question 13

Most common cause of constipation in childhood

Answer 13

Functional

Pain->apprehension->retention->passage of hard stools->cycle of withholding

Question 14

Less common Medical causes

Answer 14

Cow milk allergy
Celiac disease
Hypercalcemia
Hypothyroidism

Question 15

Less common surgical causes

Answer 15

Hirschsprung
Meconium ileus
Anatomic malformations of anus
Spinal nord abnormalities

Question 16

Behaviour modifications

Answer 16

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

Question 17

Dietary management

Answer 17

Fibre->wholewheat bread and cereals
Fluids
Stool softeners->fruit (with peel), vegetables, beans, nuts, prune juice

Question 18

Disimpaction (1-2 weeks or until symptoms resolve)

Answer 18

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

Question 19

Maintenance therapy

Answer 19

Stools should be kept soft with softener and stimulant for 6 months.
Continue with dietary and behaviour modifications

Question 20

Vigilance

Answer 20

Start or escalate treatment at first indication of recurrence of hard stools