Constipation with Overflow Flashcards
Define constipation with overflow.
A delay or difficulty in defaecation, present for >2/52 and sufficient to cause significant distress.
Overflow: With chronic constipation there is a risk that faecal impaction could occur. Liquid faeces leak around the big lump of solid faeces. There is usually associated incontinence with this presentation.
Explain the aetiology/risk factors for functional constipation with overflow.
90–95% of cases; idiopathic as nil underlying medical condition secondary to vicious cycle of pain on defecation and retention. There is association of pain with defecation and withhold stools in an attempt to reduce pain.
Explain the aetiology/risk factors for slow transit constipation (STC).
Causes intractable symptoms and normally refractory to medical management.
Explain the aetiology/risk factors for nutritional constipation with overflow.
Cow’s milk protein allergy, inadequate fluid intake, malnutrition, high refined carbohydrate and protein diet or a low-fibre diet.
Explain the aetiology/risk factors for organic (rare) constipation with diarrhoea.
Gastrointestinal anomalies; Hirschsprung’s disease, anorectal stenotic lesions, anal fissures. Spinal/neuromuscular disease. Hypothyroidism.
What is constipation with overflow generally associated with?
Cerebral palsy, delayed passage of meconium, failure to thrive encopresis.
Summarise the epidemiology of constipation with overflow.
Extremely common.
What are some symptoms of constipation with overflow?
May have delayed passage of meconium (more than 24 hours at birth is characteristic at Hirschsprung’s disease).
Reduced stool frequency depending on type of milk and solids.
What are some signs of constipation?
General: Abdominal distension and palpable stools. Sacral dimples/pits.
DRE: Anus position of perineum, presence of fissures/fistulae/stool/mass, anal wink and sensation, size of anal canal/rectum.
What are some investigations for constipation with overflow?
Radiology: AXR to assess the fecal impaction.
Anorectal manometry: Delineating child’s defecation dynamics, evidence of megarectum, exclusion of ultra-short segment Hirschsprung’s disease.
Radionuclear transit scintigraphy: Identifies slow colonic transit.
What is the management for constipation with overflow?
General: Evacuation of the colon, elimination of pain and establishment of regular defaecation routines.
Medical: Dietary changes (“d fibre, adequate fluids), exercise, laxatives/faecal softeners, enema programme, lignocaine gel (anal fissures).
Surgical intervention: Endorectal pull-through for confirmed Hirschsprung’s disease. Antegrade continence enema (ACE) either proximally (pACE/Mallone procedure) or distally (dACE). Allows the administration of enemas directly into the caecum or the distal colon.
Other: Interferential therapy (transcutaneous electrical stimulation) is a possible future therapy.
What are potential complications of constipation with overflow?
Faecal overload, emotional and behavioural difficulties.
What is the prognosis of constipation with overflow?
50% recover within 1 year and the majority over 2 years.
