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Constipation

Constipationis difficult passage of hard stools. Clinical problem is not infrequent passageper se, but difficult and painful bowel movements.

Common manifestations include crampyabdominal pain, abdominal distension, anorexia, irritability, andurinary frequency.

Principal Causes of Constipation

1. Constitutional
   1. Geneticpredisposition
   2. Colonic inertia
2. Dietary factors
3. Developmental, situational, and psychologicdisturbances
4. Gastrointestinal disorders
   1. Anal fissure
   2. Anal stenosis
   3. Anterior location of the anus
   4. Proctitis
   5. Congenital aganglionic megacolon
   6. Cystic fibrosis
   7. Celiac disease
   8. Chronic intestinal pseudoobstruction
5. Abdominal, pelvic, and sacral masses
6. Neurologic disorders
   1. Mentalretardation
   2. Spinal dysraphism
   3. Spinal cord injury
   4. Spinal tumor
   5. Neuromuscular disorders
7. Metabolic disorders
8. Drugs

Clinical Features and Diagnosis

Constitutional

Some children seem to have predispositionto passage of hard, infrequent bowel movements. Others have colonicinertia with delayed transit time and increased absorption of fluidin colon.

Dietary Factors

Inadequate fluid intake or high-protein dietwithout enough fiber are common factors predisposing to constipation.Undernutrition also may produce constipation.

Developmental, Situational, and Psychologic Disturbances

Often intertwineddevelopmental, situational, and psychologic factors may result in developmentof constipation. In such cases, stool pattern usually is normaluntil toilet training begins at 2–3 yrs. Excessive parentalconcern and forced attempts at defecation often cause conflict thatresults in fecal retention. Common response to negative toilet-trainingexperience or unresolved conflict between child and parent is withholdingof bowel movement.

Purposefully avoiding bowel movementduring travel or while at school is another common cause.

Stress that produces anxiety or depressionalso may produce constipation because of inability to attend toneed for defecation.

Gastrointestinal Disorders

Anal Fissure

Tear in anal mucosa may contribute to constipationbecause children withhold stool rather than experience pain duringbowel movement. Fissures are readily seen on exam of anus.

Anal Stenosis

Less commonanatomic cause. Entire canal or any portion may be involved. Mayoccur in normal child or follow surgical repair of anal atresiaor other anorectal problems.

Digital exam or endoscopy confirmsdiagnosis.

Anterior Location of Anus

In thisunusual cause, anal opening is closer to vagina or scrotum thannormal.

Diagnosis is made by visual inspection.

Proctitis

Pain associatedwith proctitis may cause a child to withhold stool, so that constipation develops.

Rectal trauma (foreign body) and sexualabuse are common causes of proctitis.

History, physical exam, and proctoscopyare diagnostic.

Congenital Aganglionic Megacolon (Hirschsprung Disease)

Absenceof ganglion cells in affected segment of intestine is responsiblefor this disorder. Delayed passage of meconium at birth is characteristic.

Common manifestation is infrequentpassage of small, hard stools. Slow weight gain, abdominal distension,and empty ampulla on rectal exam are frequent findings.

Suction rectal biopsy with acetylcholinesterasestaining can establish diagnosis. Otherwise, full-thickness rectalbiopsy sample that shows absence of ganglion cells is diagnostic.

Manometric studies may help in somecases.

Cystic Fibrosis

Childrenbeyond neonatal period may develop inspissation of intestinal contentsin terminal ileum, cecum, and proximal colon. Formerly called meconiumileus equivalent, this condition is now known as distal intestinalobstruction syndrome.

Usual findings are vomiting, abdominalpain, and failure to pass bowel movements. Intestinal obstructionrequiring surgery may occur in some cases.

See Chap.10, Cough, and Chap.14, Diarrhea.

Celiac Disease

Althoughdiarrhea is usually the presenting symptom of celiac disease andoccurs in most cases, a few children may have constipation and markedabdominal distension.

See Chap.14, Diarrhea.

Chronic Intestinal Pseudoobstruction

Rare groupof familial and nonfamilial disorders of gastrointestinal smoothmuscle and enteric nervous system associated with ineffective intestinalmotility.

Besides constipation, vomiting, crampyabdominal pain, and abdominal distension also may occur.

See Chap.55, Regurgitation and Vomiting.

Abdominal, Pelvic, and Sacral Masses

Large abdominal,pelvic, or sacral mass may compress colon and rectum and cause constipation.

Besides abdominal exam, abdominal radiography,abdominal U/S, CT, and MRI are useful in locating and definingextent of mass.

See Chap.1, Abdominal Masses.

Neurologic Disorders

Neurologicallyimpaired children may have constipation because of difficulty in learningproper bowel control. Common example is mental retardation.

Constipation also may be associatedwith spinal dysraphism, spinal cord injury, or spinal tumor becauseof damage to sensory and motor nerves in T12–S3 distribution.History and physical exam with absence of cremasteric reflex andanal wink along with poor rectal tone should suggest diagnosis.CT and MRI locate and define extent of lesions.

Neuromuscular disorders (e.g., spinalmuscular atrophy, myasthenia gravis, muscular dystrophies, and infantbotulism) also may result in constipation.

See Chap.33, Hypotonia and Weakness.

Metabolic Disorders

Constipationmay occur with hypothyroidism and diabetes insipidus.

See Chap.23, Growth Deficiency: Weight and Height, and Chap. 47, Polyuria and Polydipsia.

Drugs

Some commonly used drugs that may produceconstipation include opioids, diuretics, anticholinergics, antacids(aluminum), phenytoin, and calcium channel blockers.

Diagnostic Approach

Diagnosisof many causes of constipation can be made by history and physicalexam.

Age is a key factor. Although neonatesare more likely to have anatomic cause, most common causes in infantsand children are inadequate fluid and fiber in diet and combinationof developmental, situational, and psychologic factors.

Physical exam is usually normal withmild constipation, whereas with severe constipation, stool is oftenpalpable in lower left quadrant and rectum is filled with hard feces.

Abdominal radiograph shows presenceof stool, its extent, and whether lower spine is normal.

If constipation fails to improve withusual therapy of adequate fluid intake, high-fiber diet, and laxatives,other disorders (e.g., congenital aganglionic megacolon) shouldbe suspected.

References

1. Abi-Hanna A, Lake AM. Constipation andencopresis in childhood. Pediatr Rev 1998;19:23–30.
2. Croffie JMB, Fitzgerald JF. Idiopathic constipation.In: Walker WA, et al., eds. Pediatric gastrointestinal disease,3rd ed. Hamilton, Ontario, Canada: BC Decker, 2000:830–844.
3. Fitzgerald JF. Constipation in children. Pediatr Rev1987;8:299–302.
4. Lewis LG, Rudolph CD. Practical approach to defecationdisorders in children. Pediatr Ann 1997;26:260–268.
5. Loening-Baucke V. Chronic constipation in children.Gastroenterology 1993;105:1557–1564.
6. Markowitz J, Ludwig S. Constipation. In: Fleisher G,Ludwig S, eds. Textbook of pediatric emergency medicine, 4th ed.Philadelphia: Lippincott Williams & Wilkins, 2000:177–181.
7. Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.

Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics Authors: Paul S. Bellet Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 0-78172-899-1

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