Paeds: Constipation Flashcards
Normal bowel movements
‘Normal frequency’ of defaecation is highly variable and varies with age. Average of four stools a day.
Definition:
Infrequent passage of dry, hardened faeces often accompanied by straining or pain. May be abdominal pain which waxes and wanes with passage of stool or overflow soiling
Idiopathic
Commonest due to a combination of:
- Low fibre diet
- Lack of mobility and exercise
Poor colonic motility (55% have a positive family history)
Gastrointestinal
Hirschsprungs disease Anal disease (infection, stenosis, ectopic, fissure, hypertonic sphincter) Partial intestinal obstruction Food hypersensitivity Coaliac disease
Non-gastrointestinal
- Hypothyroidism
- Hypercalcaemia
- Neurological disease e.g. spinal disease
- Chronic dehydration e.g. diabetes insipidus
- Drugs e.g. opiates and anticholinergics
Sexual abuse
Presentation:
- Straining and/or infrequent stools
- Anal pain on defeacation
- Fresh rectal bleeding (anal fissure)
- Abdominal pain
- Anorexia
- Involuntary soiling or spurious diarrhoea (liquid faeces passess around solid impaction
- Flatulence
- Reduced growth
- Abdomial distension
- Palpable abdominal or rectal faecal masses, usually indentible
- Anal fissure
- Abnormal anal tone – only if anal stenosis is suspected
Investigations: Usually not necessary. If an organic cause is suspected, consider:
- FBC
- coeliac antibody screen
- TFTs
- serum Calcium
- RAST testing
- AXR
- Bowel transits studies (older child)
- Rectal biopsy (for hirschsprung’s disease
- Anal manometry
- Spinal imaging (neurological cause)
Note:
May be precipitated by dehydration or reduced fluid intake or an anal fissure causing pain.
Progression:
Progression:
Long-standing constipation, the rectum becomes over distended, with a subsequent loss of feeling the need to defecate.
Dietary advice
- Increase oral fluid intake
- Natural laxatives e.g. fruit juice
Behavioural measures: toilet foot rests, 5 min toilet time after meals; star charts and rewards for child passing stool; re
Progression of management
- Regular oral faecal softerners e.g. Movicol, lactulose or sodium docusate will aid disimpaction
- Oral stimulant laxatives e.g. senna, sodium picosulphate may ne required
- Consider treatment of anal fissure with topical anaesthetic (2% lidocaine ointment) to reduce pain and remove voluntary inhibition to defaecate.
- Oral magnesium citrate, magnesium phosphate or large volume polyethylene glycol (PEG) electrolyte solution bowel clean out (may require NG admin for rapid infusion
- Enemas e.g. Micralax or phosphate enemas, only fi no response to intensive treatment with above
Hospital admin for manual evac
Disimpaction
a. Achieved using a disimpaction regimen of stool softeners, initially with a macrogol laxative e.g. polyethylene glycol + electrolytes (Movicol Oaediatric Plain)
b. If unsuccessful a stimulant laxative e.g. senna or sodium picosulphate
Maintenance
Polyethylene glycol (with or without stimulant laxative) Dose should be reduced over a period of months in response to improvement in stool consistency and frequency.
Failure to pass meconium within 24h of life
Hirschsprung disease
Failure to thrive/growth failure
Hypothyroidism, coeliac disease, other causes
