Gastro - constipation Flashcards
How can constipation be defined in children?
Infrequent passage of dry, hardened faeces, often accompanied by straining or pain.
Which causes for constipation need to be considered in babies?
Hirschprung’s disease
Anorectal abnormalities
Hypothyroidism
Hypercalcaemia
What are the red flags in constipation? (relating to motility disorders)
Failure to pass meconium in first 24 hours (Hirschprung’s disease)
Failure to thrive (hypothyroid, coeliac)
Gross abdo distension (Hirschprung)
Abnormal anorectal appearance (anatomy)
Abnormal lower limb neurology/deformity - Lumbosacral pathology
Perianal bruising or multiple fissures (sexual abuse)
Perianal fistulae, abscesses or fissures - perianal Crohns
How is acute constipation managed?
Faeces usually not palpable per abdomen:
Often resolves spontaneously (eg. after acute febrile illness)
or with mild laxatives and extra fluids
Balanced diet
What is the first step in managing constipation, if faeces palpable per abdomen?
Macrogol laxative, eg. polyethylene glycol + electrolytes
2 weeks
If after first line treatment, the patient has not passed stool, what is the second line treatment?
Stimulant laxative
(eg. senna or picosulphate)
+/- osmotic laxative (eg. lactulose)
If second line does not succeed, what other management is available?
Enema (+/- sedation)
Or Manual Evacuation under GA by paediatric specialist
What is Hirschprung’s disease and its aetiology?
Absence of ganglion cells from myenteric submucosal plexuses in large bowel, leading to narrow, contracted segments.
75% of cases, the lesion is confined to rectosigmoid.
In 10%, the entire colon is involved.
Caused by failure of ganglion cells to migrate into the hindgut
Absence of coordinated bowel persitalsis and functional bowel obstruction
How does Hirschprung’s disease present?
Failure to pass meconium within first 24 hours of life.
LATER:
Abdominal distension and bile-stained vomiting develop.
Occasionally, there is severe, lifethreatening Hirschprung enterocolitis during first weeks of life ( C. difficile)
In later childhood: presents with chronic constipation plus abdo distension, but without soiling
Possible growth failure
What are the management options for Hirschprung’s disease in neonates?
To manage intestinal obstruction initially:
Rectal washouts
+
Broad spectrum IV antibiotics (enterocolitis)
+
NasoGastricTube decompression
If fails, colostomy may be required
then surgery to remove aganglionic segment
Normal stool frequency in infancy
4 per day
2 per day by 1 year
Adult pattern by 4 years
Causes of constipation
Serious: Hirschprungs Hypothyroidism Hypercalcaemia Anorectal abnormalities
More commonly:
Dehydration
Reduced fluid intake
Anal fissure causing pain
Or toilet training, or stress
Encopresis
Medical term for a toilet trained child (4yrs) soiling their clothes
Functional encopresis
Rare
More psychologica
Never toilet trained or toilet phobia or manipulative soiling or IBS
Overflow encopresis
Colon completely full so stools force their way out
