Constipation

Question 1

What is constipation?

Answer 1

infrequent passage of stool specific to individual

Question 2

What tool can you use to evaluate stool production?

Answer 2

bristol stool chart 1=hardest, 7=softest

Question 3

What are other signs ad symptoms of constipation other than infrequency of bowel movement?

Answer 3

• poor appetite
• irritable
• lack of energy
• abdominal pain or distension
• withholding or straining
• diarrhoea!

Question 4

Why do children become constipated?

Answer 4

• poor diet
• potty training/ school toilet anxiety
• intercurrent illness
• medications
• family history
• psychological (secondary)
• organic

Question 5

What is the vicious cycle of constipation?

Answer 5

large hard stool—pain or anal fissure–withholding of stool—constipation

Question 6

What social treatment can there be for constipation?

Answer 6

• dietary e.g. increase fibre, fruit, veg, fluids ad reduce milk intake
• reduce aversive factors
• soften stool and remove pain e.g. lactulose (osmotic) or movicol (isotonic)
• reward ‘good’ toileting behaviour

Question 7

What should you do if you initiate ac child on laxative treatment for constipation?

Answer 7

continue this as treatment for about half the time the child has had the problem

Question 8

What can chronic constipation lead to?

Answer 8

bowel impaction

Question 9

How would you treat impaction?

Answer 9

• empty impacted rectum (laxatives)
• empty colon (laxatives)
• maintain regular stool passage
• slow weaning off treatment

Question 10

What might make you suspect that a child with constipation has impaction?

Answer 10

• may have big abdominal mass like a gravid uterus

- diarrhoea due to overflow

Question 11

What 2 conditions comprise Inflammatory Bowel Disease?

Answer 11

• Crohn’s disease

- Ulcerative colitis

Question 12

What are differences between presentations of Crohn’s and Ulcerative colitis?

Answer 12

• Diarrhoea is a more prominent feature of UC
• rectal bleeding is a more prominent feature of UC
• abdominal pain is common to both
• fever may or may no be present in both
• weight loss is more prominent in Crohn’s
• growth failure is more prominent in Crohn’s
• arthritis may be present in either
• sometimes a mass can be palpated in Crohn’s

Question 13

What can you do with history and examination to hone in on a diagnosis of IBD?

Answer 13

• intestinal symptoms
• extra-intestinal manifestations
• exclude infection by stool culture (campylobacter is also a cause of bloody diarrhoea)
• family history - high genetic component
• growth and sexual development -as affects duet (particularly Crohn’s)
• nutritional status

Question 14

What laboratory investigations can be carried out to investigate IBD?

Answer 14

Biochemistry

• STOOL CALPROTECTIN
• raised CRP
• low albumin

FBC and ESR

Microbiology
-make sure there are no stool pathogens

Question 15

What are definitive investigations into IBD?

Answer 15

-radiology (especially Crohn’s) e.g. MRI, barium meal and follow through

-endoscopy
colonoscopy (all)
upper GI endoscopy (all)
mucosal biopsy
capsule endoscopy

Question 16

What might you see on endoscopy that would be suggestive of IBD?

Answer 16

• Crohn’s skip lesions, like snail trails

- UC may see ulcers and very red in rectum

Question 17

What are medical treatments of IBD?

Answer 17

• anti-inflammatory
• immunosuppressive e.g. azathioprine
• biologics e.g. infliximab

Question 18

What is an uncommon side effect of azathioprine?

Answer 18

lymphoma

Question 19

What are nutritional treatments for IBD?

Answer 19

• nutritional supplementation

- Crohn’s is often managed exclusively by nutritional therapy