Paeds: Constipation Flashcards Preview

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Flashcards in Paeds: Constipation Deck (22):
1

Normal bowel movements

‘Normal frequency’ of defaecation is highly variable and varies with age. Average of four stools a day.

2

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

3

Idiopathic

Commonest due to a combination of:
- Low fibre diet
- Lack of mobility and exercise
Poor colonic motility (55% have a positive family history)

4

Gastrointestinal

Hirschsprungs disease
Anal disease (infection, stenosis, ectopic, fissure, hypertonic sphincter)
Partial intestinal obstruction
Food hypersensitivity
Coaliac disease

5

Non-gastrointestinal

- Hypothyroidism
- Hypercalcaemia
- Neurological disease e.g. spinal disease
- Chronic dehydration e.g. diabetes insipidus
- Drugs e.g. opiates and anticholinergics
Sexual abuse

6

Presentation:

1. Straining and/or infrequent stools
2. Anal pain on defeacation
3. Fresh rectal bleeding (anal fissure)
4. Abdominal pain
5. Anorexia
6. Involuntary soiling or spurious diarrhoea (liquid faeces passess around solid impaction
7. Flatulence
8. Reduced growth
9. Abdomial distension
10. Palpable abdominal or rectal faecal masses, usually indentible
11. Anal fissure
12. Abnormal anal tone – only if anal stenosis is suspected

7

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)

8

Note:

May be precipitated by dehydration or reduced fluid intake or an anal fissure causing pain.
Progression:

9

Progression:

Long-standing constipation, the rectum becomes over distended, with a subsequent loss of feeling the need to defecate.

10

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

11

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

12

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

13

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.

14

Failure to pass meconium within 24h of life

Hirschsprung disease

15

Failure to thrive/growth failure

Hypothyroidism, coeliac disease, other causes

16

Gross abdominal distension

Hirschsprungs disease or other gastrointestinal hysmotility

17

Abnormal lower limb neurology or deformity e.g. talipes or secondary urinary incontinence

Lumbrosacral pathology

18

Sacral dimple above natal cleft, over the spine – naevus, hairy patch, central pit, or discoloured skin

Spina bifida occulta

19

Abnormal appearance/position/patency of anus

Abnormal anorectal anatomy

20

Perianal bruising or multiple dissures

Sexual abuse

21

Perianal fistulae, abscesses or fissures

Perianal Crohn disease

22


Prognosis:

Cured by an enthusiastic and sympathetic paediatrician with complete evacuation of any stool masses, maintaining soft stools and defecation training.

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