Constipation

Constipation: Excerpt from The 5-Minute Pediatric Consult

Kristin N. Fiorino, MDMaria R. Mascarenhas, MBBS

Constipation - BASICS

Constipation - description

Delay or difficulty in defecation present for ≥2 weeks which may result in pain, rectal bleeding, and encopresis or soiling. May refer to a decrease in frequency of bowel movements compared with the patient’s usual bowel pattern.

Constipation - general prevention

Dietary measures: High-fiber diet, plenty of fluids, avoidance of excessive caffeine and milk (calcium) intake, plus regular physical activity

Constipation - pathophysiology

• Retention of stool allows water to move out of stool, increasing size and firmness.
• Decreased motility leads to retention of stool. Often there is a family history of motility disturbances or constipation.

Constipation - etiology

• Most patients will have idiopathic or functional constipation with no identifiable cause: Usually an acute event followed by chronicity.
• Intentional or unintentional withholding of stool may result in hard stools, anal pain, and fissures that perpetuate and lead to constipation: Rectal dilatation, decreased sensation of the urge to defecate, shortening of the anal canal, decreased tone of the external anal sphincter, and encopresis can result.
• Precipitating events include:
  • Transition from breast milk to cow’s milk
  • Power struggle in toddlers
  • Refusal to use toilets outside the home
  • Perianal streptococcal infection
  • Transient viral illness (diarrhea followed by constipation)
  • Zealous toilet training
• Constipation also can be caused by anatomic anomalies in the lower GI tract, decreased propulsion, impaired rectal sensation (primary or secondary), or a functional outlet obstruction (muscular spastic levator ani or impaired relaxation of the puborectalis).
• Neurologic causes:
  • Abnormalities of the myenteric plexus
  • Intestinal pseudo-obstruction
  • Congenital aganglionosis
  • Intestinal neuronal dysplasia
  • Muscular diseases (visceral myopathies)
  • Lesions of the spinal cord result in loss of rectal tone and sensation and reduced anal closure, affecting the sacral reflex center (e.g., myelomeningocele, spina bifida occulta, tethered cord).
• Anatomic disorders of anus and rectum (stricture, stenosis, mass, ectopic anus, imperforate anus, fistula)
• Endocrine abnormalities (hypothyroidism), drugs, electrolyte abnormalities

Constipation - DIAGNOSIS

Constipation - signs & symptoms

Constipation - history

• Question: What is the timing of the passage of meconium?
  • If it is delayed for >48 hours, consider Hirschsprung disease.
• Is the child able to pass a bowel movement unaided by a suppository or enema?
  • If rectal stimulation is required for passage of a bowel movement, consider Hirschsprung disease or habituation to rectal stimulation.
• What are the size, frequency, and consistency of bowel movements?
  • 1–3 normal (in size and consistency) painless bowel movements may be passed every 1–3 days. The size of bowel movements reflects the caliber of the colon.
• Does the child experience frequent urination, bed wetting, or urinary tract infections?
  • Frequently linked to chronic constipation
• Is there soiling?
  • Soiling occurs if the stool is impacted or with nerve damage involving the anus.
• Is there the presence of rectal sensation?
  • Patients with long-standing constipation or withholding who develop a dilated rectum may lose the sensation of rectal distention.
• Is there a history of painful bowel movements or rectal fissure?
  • This could be the cause of withholding secondary to fear of painful bowel movements.
• Is the child experiencing any stressful events (i.e., new sibling, family death)?
  • Stress can precipitate stool withholding.
• Is there an unsteady gait?
  • This may suggest neuromuscular problems.
• Did the child experience difficult toilet training?
  • May be associated with encopresis

Constipation - physical exam

• General: Look for evidence of systemic illness.
• Abdomen: Abdominal distention (indicative of the presence of stool or gas), presence of stool masses (size, location), distended bladder, and bowel sounds (may be decreased in intestinal pseudo-obstruction)
• Rectal examination:
  • Perianal soiling
  • Size and position of anus (may suggest imperforate or ectopic anus)
  • Presence of skin tags and fissures
  • Perianal or anal erythema (streptococcal proctitis)
  • Evidence of child abuse
  • On digital examination, assess anal tone (decreased in functional constipation; very long and tight anal canal in Hirschsprung); amount and consistency of stool; size of rectum (dilated rectum with chronic constipation; tight and empty anus with Hirschsprung disease); presence of blood
  • Absence of anal wink or cremasteric reflex suggests neurologic abnormalities.
• Neurologic examination: Decreased reflexes in the lower extremities
• Back: Check for sacral dimple, tuft of hair (underlying sacral abnormality), flat buttocks, and patulous anus.

• Grunting baby syndrome: Infants cry, scream, and draw up their legs during a bowel movement. They respond to rectal distention by contracting their pelvic floor. This is not constipation.
• Always rule out an organic cause.
• Always consider medications as a cause.

Constipation - tests

Constipation - lab

Barium enema: An unprepped study is useful to diagnose Hirschsprung disease. A prepped study is useful to diagnose a stricture. Most patients with constipation will not require this test.

Constipation - imaging

Abdominal radiograph study: Look for presence and location of stool and evidence of bowel obstruction.

Constipation - diag proced-surgery

Anorectal manometry: Analyzes rectal sensation, resting and squeezing pressures, and pelvic floor dyssynergia (anismus)

Constipation - differencial diagnosis

• Hirschsprung disease: Congenital aganglionic megacolon
• Neuromuscular causes: Tethered spinal cord, spinal muscular atrophy
• Anal abnormalities: Anteriorly displaced anus, ectopic anus, imperforate anus, anal stenosis
• Endocrine abnormalities: Hypothyroidism and hyperparathyroidism
• Electrolyte imbalance: Hypokalemia, hyponatremia, hypomagnesemia, hypercalcemia
• Lead ingestion: Anemia, constipation, and abdominal pain
• Infant botulism: Constipation, aphonia, and weakness
• Meconium ileus: Inspissated stool at birth in cystic fibrosis
• Inflammatory bowel disease (IBD)
• Celiac disease (gluten enteropathy)
• Abdominopelvic mass: Can cause constipation by pressure (i.e., distended bladder or pelvic tumor); pregnancy can also cause constipation.
• Chronic intestinal pseudo-obstruction: Abdominal distention, diarrhea, and constipation
• Surgical conditions: Malrotation, congenital intestinal bands, intestinal stenoses, acquired colonic strictures resulting from IBD, necrotizing enterocolitis (NEC), pyloric stenosis
• Drugs: Calcium supplements, iron, barium, opiates, anticholinergic agents

Constipation - TREATMENT

Constipation - general measures

• Treatment of functional constipation:
  • Disimpaction: If patient is impacted, 3–5 hypertonic phosphate enemas may be required for initial disimpaction. Children >2–3 years of age require adult-size enemas, whereas younger children require pediatric-size enemas.
  • Evacuation: Following rectal disimpaction, evacuation can be achieved by using polyethylene glycol solution (Go-Lytely), orally or via nasogastric tube over 6–8 hours until the effluent is clear. Alternatively, MiraLAX, can be used on a daily basis to achieve evacuation over 1–2 weeks. Doses are given in 8 oz of water once or twice daily.
  • Maintenance stool softeners:
    • Infants ≤1 year of age may be given lactulose or Maltsupex (barley malt 1 tsp/8 oz of formula). Children >1 year of age may get lactulose or MiraLAX. mineral oil or Kondremul is added as an adjunctive lubricant to aid in the passage of stool but contraindicated in children <12–15 months.
  • Rescue stimulant laxatives: Bisacodyl or senna may be used as a stimulant laxative for short periods of time. Long-term use has been associated with colonic nerve damage in adults.
  • Diet: A balanced diet of whole grains, fruits, and vegetables is recommended. A high-fiber diet is recommended (toddler 10–12 g/d; school-aged 12–16 g/d; adolescent 16–20 g/d). Fiber should be increased gradually to minimize side effects of flatulence. Caffeine and excessive milk-product intake (>16 oz/d of milk) may be constipating.
  • Fluid intake: High fluid intake is important.
  • Toilet sitting: Regular toilet sitting twice a day for 10 minutes, preferably after meals, is necessary to help retrain the bowel.
  • Calendar: It is important to keep a record of stools, accidents, toilet sitting, and medications in order to identify causes of failure.
  • Biofeedback can be helpful in patients who fail conventional therapy and who have the following abnormalities on anorectal manometry: Decreased sensory threshold to rectal distention, paradoxical contraction of the external anal sphincter and puborectalis muscle during simulated defecation (pelvic floor dyssynergia)
• Treatment of complications:
  • Encopresis (soiling or diarrhea): Abdominal radiograph film shows large amounts of stool in the colon, including a dilated rectum. Disimpaction or clean-out, followed by treatment of constipation, is recommended (see above).
  • Intestinal obstruction: Vomiting, abdominal pain, and constipation. Abdominal radiograph film shows intestinal obstruction. Make nulla per os, give IV fluids, and rule out an acute abdomen. Then give enemas and clear out stool from below. Never give oral laxatives or a polyethylene glycol solution in a case of obstruction.
  • Sigmoid volvulus: Chronically constipated child with symptoms of acute abdomen, fever, tender abdomen, and palpable mass. Abdominal radiograph shows obstruction in the colon. Contrast enema may reveal and possibly reduce a volvulus.

Constipation - FOLLOW UP

Constipation - prognosis

For functional constipation, the success rate is variable (45–90%). Presence of abdominal pain at the time of presentation, close follow-up, and use of mineral oil are good prognostic factors. Presence of soiling, use of Senokot, and lack of follow-up were associated with failure.

Constipation - complications

• Anal fissures: Infrequent hard stools can cause a tear of the anal mucosa, causing pain and withholding.
• Encopresis: Chronic constipation leads to progressive rectal dilatation and decreased rectal sensation. Fecal impaction results in secondary soiling or encopresis.
• Intestinal obstruction: Manifests as vomiting, abdominal pain, and constipation. Abdominal radiograph films show intestinal obstruction and presence of large amounts of stool.
• Sigmoid volvulus: A chronically constipated child may present with symptoms of acute abdomen, fever, tender abdomen, and palpable mass. Abdominal radiograph shows obstruction in the colon. Barium enema may be both diagnostic and therapeutic by achieving reduction.

Constipation - patient monitoring

• Schedule regular visits to make certain therapy is maintained, decreasing the frequency of visits when patient is doing well.
• Parents should call when problems develop.
• Compliance and good follow-up are key to successful management of constipation.

Constipation - bibliography

1. Baker SS, Liptak GS, Colletti RB, et al. Evaluation and treatment of constipation in infants and children: Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43:e1–e13.
Croffie JM, Fitzgerald J. Idiopathic constipation. In: Walker WA, et al. Pediatric Gastrointestinal Disease, 4th ed. Philadelphia: BC Decker; 2004:1000–1055.
2. Lewis LG, Rudolph CD. Practical approach to defecation disorders in children. Pediatr Ann. 1997;26:4260–4268.
3. Loening–Baucke V. Encopresis and soiling. Pediatr Gastroenterol. 1996;43:1279–1297.
4. Pashankar D, Loening-Baucke V, Bishop W. Safety of polyethylene glycol 3350 for the treatment of chronic constipation in children. Arch Pediatr Adolesc Med. 2003;157:661–664.
5. Setty R, Wershil B. Fecal overflow incontinence. Pediatr Rev. 2006;27:e54–e55.
6. Youssef N, Peters JM, Henderson W, et al. Dose response of PEG 3350 for the treatment of childhood fecal impaction. J Pediatr. 2002;141:410–415.

Constipation - CODES

Constipation - icd9

564.0 Constipation

Constipation - FAQ

• Q: When is constipation an emergency?
• A: When intestinal obstruction, sigmoid volvulus, or Hirschsprung enterocolitis occurs.
• Q: Does MiraLAX have a taste?
• A: MiraLAX advantages include its lack of taste, smell, or odor and that it can be mixed in any liquid.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Constipation

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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