GI/ Liver Flashcards
How many children are affected by constipation?
5-30% children. About a third develop chronic symptoms. Peak incidence is around 2-3 years (toilet training age)
How is constipation characterised in children?
Infrequent bowel evacuations
Large stools
Difficult or painful evacuation.
What is a normal stool frequency in the first week of life?
4 x a day
What is a normal stool frequency at 1 year of age?
2 x a day. Breastfed infants tend to be less regular
When is the normal adult range of passing stools attained in childhood?
The normal adult range (between 3 stools per day and 3 stools per week) is usually attained by 4 years of age.
How do you define chronic constipation?
Two or more of the following for 8 weeks:
- Fewer than 3 bowel movements/ week
- More than one episode of faecal incontinence/week
- Stool palpable in the abdomen or rectally
- Passing stools so large they block the toilet
- Retentive posturing and withholding behaviours
- Painful defecation
What is incontinence resulting from disease called?
Organic faecal incontinence
What is incontinence not caused by organic disease called?
Functional faecal incontinence (90-95% of cases). Can be either:
- Constipation associated faecal incontinence
- Non retentive faecal incontinence (passage of stools in inappropriate places in children over the age of 4 with no organic disease/ constipation/ identifiable cause.
What is faecal impaction?
Large faecal mass (felt in abdo/ rectum) that is unlikely to be passed on demand.
What should a constipation history include?:
In addition to general history (past medical history, school and social history and family history, birth history)
-Parents can mistake incontinence for diarrhoea. In infants aged under 6 months, straining and crying for 10 minutes before passage of stools is caused by dyschezia (painful or difficult defecation which resolves spontaneously) and may be mistaken for constipation.
Specific questions should cover: The frequency of defecation. Consistency of stools - this may include use of the Bristol Stool Chart Episodes of faecal incontinence. Pain on defecation. Whether stools block the toilet. Any associated behaviour. Any pain on defecation is likely to lead to withholding.
Check for features in the history which are suggestive of idiopathic constipation, including:
- Meconium passed within 48 hours of birth (in a full-term baby).
- Onset of constipation at least a few weeks after birth.
- Presence of precipitating factors e.g.Dietary factors (for example changes to infant formula or weaning, poor diet, or insufficient fluid intake), Acute illness, such as infection, Anal fissure, Use of drug treatments such as sedating antihistamines or opiates, Timing of potty or toilet training, Psychosocial factors such as difficulty accessing a toilet, moving house, starting nursery or school, other major change in family circumstances, and fears and phobias.
Specific examination in constipation should include:
- Palpation of the abdomen for faecal mass.
- Inspection for anal stenosis or ectopia.
- Looking for sacral abnormalities.
NB:
Rectal examination is not routinely necessary or required.
Name some organic causes of constipation:
- Anorectal malformations e.g. atresia, anus not in right place
- Cow’s milk allergy
- Hirschprungs (presents very early)
- Spinal cord problems
- Metabolic/systemic e.g. CF, hypothyroidism, coeliac, hypercalcaemia
- Neuroenteric problems- e.g. decreased gastric mobility
- Pelvic floor dysynergia- inability to relax pelvic floor when attempting to defecate
Functional causes of constipation:
Contributing factors for constipation include pain, fever, inadequate fluid intake, reduced dietary fibre intake, toilet training issues, the effects of drugs such as sedating antihistamines or opiates, psychosocial issues, and a family history of constipation.
Constipation is more common in children who are physically inactive or with impaired mobility (for example children with cerebral palsy) or a neurodevelopmental disorder (such as Down’s syndrome or autistic spectrum disorder).
Complications of idiopathic constipation:
- Anal fissure, which may exacerbate a vicious cycle of pain leading to stool withholding, hard stool, and ongoing constipation.
- Haemorrhoids.
- Rectal prolapse.
- Megarectum- impaired sensation and soiling
- Faecal impaction and soiling.
- Volvulus.
- Distress for the child and family, physical discomfort, missed school, poor school performance, social isolation, and reduced involvement in group activities.
Symptoms associated with defecation in a child older than 1 year of age:
- Poor appetite that improves with passage of large stool.
- Waxing and waning of abdominal pain with passage of -stool.
- Evidence of ‘retentive posturing’ — typical posture is straight-legged, on tiptoes with an arched back.
- Anal pain.
Symptoms associated with defecation in children of any age:
- Distress or pain on passing stool.
- Bleeding associated with hard stool.
- Straining.
Red and amber flags in constipation:
- Symptoms of constipation appearing from birth or during the first few weeks of life — may indicate Hirschsprung’s disease (congenital aganglionic megacolon).
- Delay in passing meconium for more than 48 hours after birth, in a full-term baby — may indicate Hirschsprung’s disease or cystic fibrosis.
- Abdominal distention with vomiting — may indicate Hirschsprung’s disease or intestinal obstruction.
- Family history of Hirschsprung’s disease.
- Ribbon stool pattern — may indicate anal stenosis (more likely to present in a child younger than 1 year of age).
- Leg weakness or motor delay — may indicate a neurological or spinal cord abnormality.
- Examination may reveal unexplained lower limb deformity or abnormal neuromuscular signs, including abnormal reflexes.
- Abnormal appearance of the anus (including fistulae; bruising; fissures; tight or patulous [widely patent] anus; anteriorly placed anus; or an absent anal wink [a reflex contraction of the external anal sphincter when the skin around the anus is stroked, may indicate spinal or neurological pathology]).
- Abnormalities in the lumbosacral and gluteal regions (such as asymmetry of the gluteal muscles, evidence of sacral agenesis, scoliosis, discoloured skin, naevi, hairy patch, sinus or central pit).
Amber flags also require specialist referral for assessment, but children with these signs may be treated for constipation in primary care whilst awaiting specialist assessment. They include:
Evidence of faltering growth, developmental delay, or concerns about wellbeing, which may indicate a systemic condition — liaise with a specialist to arrange testing for possible coeliac disease, hypothyroidism, cystic fibrosis, and electrolyte disturbance, if appropriate.
Constipation triggered by the introduction of cows’ milk
Concern of possible child maltreatment
Management of constipation in red flags:
Do not treat, refer for urgent paediatric review
Management of constipation with amber flags:
If there is evidence of faltering growth, treat for constipation and test for coeliac disease and hypothyroidism.
If there is evidence of possible child maltreatment, treat for
constipation and refer to guidelines on suspected child abuse.
Management of idiopathic/functional constipation:
- Inform the child, parent and carers of diagnosis and there is no worrying features. Reassure and advise that treatment can take months.
- Assess for faecal impaction- overflow incontinence. If present, follow protocol.
- Give diet and lifestyle advice (fibre, fluids, exercise).
- Liaise with the school nurse.
- Refer if there is no response within three months.
