Constipation

Question 1

Differential diagnosis of constipation

Answer 1

• Functional constipation
  
  • Retention of stool (?pain, ?fear) → Accumulation and hardening of stool → Pain
• Dietary
  
  • Lack of fluids and fibre
  • Too much milk (feel full, don’t eat enough fibre)
• Hirschprung disease
  
  • Aganglionic large intestine → inability to relax
  • Characterised by:
    
    • Failure to pass meconium within 24h
    • Abdominal distension
    • Vomiting
• Cystic fibrosis
  
  • Meconium ileus is pathognomic
• Anal stenosis
  
  • Toothpaste-like stools
• Hypothyroidism
  
  • ↓ gastric motility
• Food intolerances
  
  • Coeliac
  • Cow’s milk intolerance
• Medication
  
  • Opioid analgesics

Question 2

Common milestones for constipation

Answer 2

• Weaning onto solid foods / cow’s milk (~6 months)
• Toilet training
• Beginning school

Question 3

History of constipation

Answer 3

• Stool
  
  • Frequency
  • Consistency
    
    • Tooth-paste-like stools? (anal stenosis)
  • Block toilet?
• Associated symptoms?
  
  • Pain
  • Blood
  • Faecal incontinence (Soiling)
  • Abdominal distension + vomiting
• Triggers?
  
  • Weaning
    
    • Breast → formula
    • Solids
  • Toilet training
  • Starting school
• Dietary history
  
  • Fluids, fruit and veg (fibre)
  • Too much milk?
  • Allergies?
• History of passage of meconium
• Any problems with toilet training?
• Significant life events? (including bullying)
• Hypothyroidism
  
  • Weight gain
  • Cold intolerance
  • Dry skin/hair
  • Lethargy
• What have they tried? Why discontinued?

Question 4

Management of constipation

Answer 4

• Osmotic laxatives
  
  • Movicol
  • Lactulose