Constipation

Question 1

Definition of chronic constipation (4)

Answer 1

lasting 8wks plus 2 of:

• <3motions/wk
• 1 episode of foecal incontinence
• palpable stools in abdomen/PR

Question 2

Organic causes of constipation (9)

Answer 2

Local:

• hirschprung’s
• neuromuscular disorders e.g. cerebral palsy
• strictures
• volvulus

systemic:

• hypothyroidism
• coeliac
• food allergy (non-IgE mediated)
• CF-meconium ileus
• hypercalcaemia

Question 3

Hx questions for constipation (5)

Answer 3

frequency/consistency of stools

pain

blood

soiling/incontinence

urinary Sx/UTIs

Question 4

Examination of constipated child (4)

Answer 4

check systemic signs of faltering growth

check abdo distention/palpable descending colon

presence of anal fissure

DRE only if underlying condition suspected

Question 5

Red flag features of constipation (5)

Answer 5

meconium ileus/Sx in first few wks of life

abdominal distention/vomitting

delay in walking

ribbon stools-Hirschprung’s

faltering growth

Question 6

Red flag conditions causing constipations (4)

Answer 6

CF

Hirschprung’s

hypothyroidism

coeliac

(refer immediately)

Question 7

initial Mx of constipation (4)

Answer 7

increase dietary fibre and fluid intake-not sufficient as monotherapy.

Movicol 1st line-osmotic laxative. continue for 6mo

if no response in 2wks, add stimulant: senna

if not tolerated, consider lactulose/sodium docusate

Question 8

Maintenance therapy for constipation (4)

Answer 8

fluids

fibre

laxatives may need to be continued for yrs. preferably osmotic as stimulants>hypotonic colon/hypokalaemia

behaviour advice: unhurried, unstressful, reward system

Question 9

Complications of constipation (6)

Answer 9

impaction

chronic constipation

megacolon

soiling

psychological

anal fissure

Question 10

Pathology and RFs for Hirschprung’s (3)

Answer 10

congenital lack of parasympathetic ganglia cells in a section of colon>functional obstruction at birth

RFs:

• Down’s
• male

Question 11

Presentation of Hirschprung’s in infants (6)

Answer 11

delayed passage of meconium

vomitting

abdo pain/distension/obstruction

sepsis/bowel necrosis/perforation

bloody diarrhoea laden w. mucus

Hirschprung’s enterocolitis: life-threatening condition assoc. w. C. Diff

Question 12

Presentation of Hirschprung’s in older children (4)

Answer 12

chronic constipation

FTT

abdominal distension

early satiety

Question 13

Ix for Hirschprung’s (3)

Answer 13

Rectal biopsy: absence of ganglion cells

FBC: raised WCC

AXR: dilated loops of bowel

Question 14

Mx of Hirschprung’s (3)

Answer 14

obstruction:

• drip and suck
• fluids
• consider surgery

enterocolitis: Abx and fluids

surgery:

• only definitive solution
• constipation and enterocolitis may persist