Constipation and IBD Flashcards
Define constipation
Infrequent passage of stools and sensation of incomplete emptying
What questions should you ask kids that present with constipation?
How often?
How hard?
Is it painful?
Has there been a chance?
What is normal stool frequency?
4/day -1/wk
depends on age and diet
What chart can you use to assess stool consistency?
Bristol stool chart
1 - separate hard lumps = v constipated
2 - lumpy and sausage like = slightly constipated
3 - Sausage shape w cracks in surface - normal
4 - Smooth, soft sausage - normal
5 - soft blobs with clear cut edges = lacking fibre
6 - mushy consistency with ragged edges = inflammation
7 - liquid consistency w no solid pieces = inflammation
What are other signs and symptoms of constipation apart from not being able to pass stool?
Irritability Poor appetite Lack of energy Abdominal pain/distension Withholding/straining Diarrhoea
Why do some children get diarrhoea when they are constipated?
Diarrhoea can leak past hard constipated stool –> overflow soiling
What are the causes of constipation in children?
Poor diet (insufficient fluids, xs milk)
Potty training/school toilet (avoiding public toilets)
Intercurrent illness
Medication e.g. opoids/antacids
FH
Psychological (e.g. anxiety about starting school)
Organic (e.g. Hirschspurg’s disease)
What is the pathophysiology of hirschspurg disease?
Defective caudal migration of parasympathetic neuroblasts
Affected segments have absent Meissner and Auerback plexuses leading to inability of myenteric plexus to control intestinal wall muscles, spastic contractions –> stenosis, expansion of colon proximal to aganglionic section –> megacolon
What is the viscous cycle of constipation in kids?
Kid becomes constipated, large hard stool causes fissures or anal pain when trying to pass stool –> withholding –> more constipation –> more pain etc.
What is involved in treating constipation in kids?
Dietary - increase fibre, fruit, veg, fluids, decrease milk
Reduce aversive factors - correct height for child, not cold
Avoid punitive behaviour from parents
Reward good behaviour - sitting on toilet, even if they don’t defecate
Medications to soften stool and remove pain
What medications are used to soften stool and stimulate defaecation?
Osmotic laxatives, e.g. lactulose
Stimulant laxatives, e.g. senna, picolax
Isotonic laxatives, e.g. movicol
For as long as needed, take as much as they need to go
What are the advantages of using laxatives?
Non-invasive
Given by parents
What are the disadvantages of laxatives?
Non-compliance
SEs
What is impaction?
Presence of hardened fecal matter in rectum/colon due to constipation
Chronic fecal impaction is difficult to pass so can lead to more constipation and more impaction
How do you treat impaction?
Empty impacted rectum and empty colon - lacatives
Maintain regular stool passage (laxatives and slow weaning off Rx)
What is a classical presentation of CD?
Tends to be non-bloody diarrhoea
Abdominal pain
Pronounced weight loss and growth failure (as affect absorption –> anaemia, malabsorption, B12 deficiency)
Arthritis and extra-intestinal features may be present
What complications do you often get in CD and why?
Fistulas/strictures/abscesses as the CD can extend throughout the whole intestinal wall
What is a classic presentation of UC?
Bloody diarrhoea, mucus, abdominal pain, tenesmus
Rectal bleeding
Arthritis and extra-intestinal features
What extra-intestinal features can you get in UC and CD?
Uveitis (UC), arthritis, PSC (UC), skin manifestations (e.g. erythema nodosum), episcleritis (CD), fatigue etc.
What laboratory investigations should you do if you suspect IBD?
FBC & ESR - will show anaemia, thrombocytopenia, raised ESR
Biochem - stool calprotectin, raised CRP, low albumin
Do stool microbiology to rule out infections
What is fecal calprotectin an indicator of?
Intestinal mucosal inflammation
What definitive investigations should you do for IBD?
Radiology - esp CD: MRI/barium meal and follow through
Endoscopy - colonscopy, upper GI endoscopy, mucosal biopsy, capsule endoscopy, enteroscopy
What are the main differences in where CD and UC present?
CD can be anywhere from mouth to anus, tends to be skip lesions and can affect full thickness of the intestinal walls (hence why you get fistulas/strictures etc.)
UC is limited to the colon, is continuous inflammation and only affects the inner most lining of the colon
Where does CD most commonly affect?
Terminal ileum
What does UC look like on endoscopy?
Inflamed, red mucosa, bleeding on contact with endoscope
Ulcers and ?pseudopolyps
What does CD look like on endoscopy?
Discontinuous pattern
Pinpoint lesions
Cobblestone appearance
Fistulas/fissures
What are the aims of treatment in IBD in children?
Induce and maintain remission
Correct nutritional deficiencies
Maintain growth and development
How do you treat IBD in children?
Enteral elemental feeding +/- 5ASA (mesalazine) –> methotrexate for UC, azathioprine for CD –> biologics (infliximab) –> surgery (e.g. proctocolectomy for UC and ileostomy for CD)
