Perform a digital rectal examinationon every young child with chronic constipation to exclude underlying anatomic abnormalities that mightaccount for the constipation
Author:
William Giasi, Jr., MD
What to Do - Gather Appropriate Data
Perform a digital rectal examination on every young child with chronic constipation to exclude underlying anatomic abnormalities that might account
for the constipation such as an imperforate anus with perineal fistula, intestinal obstruction (mass effect), or Hirschsprung disease.
Constipation accounts for 5% of pediatric office visits and up to 25% of
referralstopediatricgastroenterologists.Inaddition,thisdisordermaycause
more anxiety and distress in the caregiver than the patient. Many caregivers
worry that a child's constipation is a sign of a more serious medical problem.
Constipation can be defined as the failure to completely evacuate the rectal
vault of stool.
Functional constipation that results from fecal retention is the most
commonetiologyofconstipationinchildhood,accountingforapproximately
97% of cases. The differential diagnosis of constipation is lengthy. The common organic causes of constipation include anal stenosis, imperforate anus,
anteriorly displaced anus, presacral teratoma, pelvic tumor or mass, spinal
cordabnormalities,cerebralpalsy,hypotonia,aganglionosis(Hirschsprung),
hypothyroidism, celiac disease, and cystic fibrosis.
Althoughthelikelihoodofundertakingandextensiveevaluationissmall,
an accurate history and complete physical exam is instrumental in establishing the etiology of constipation. The physician must be aware of red-flags
in both the history and physical exam that would indicate an uncommon
organic etiology.
The patient's history should begin from birth and include the birth history, timing of meconium passage, feeding history, changes in feeding type,
and initiation of solid foods. In addition, it is important to gather accurate
data on developmental milestones, such as the transition from diapers to
toilet training, and a social history. The family history should be reviewed
for evidence of genetic disorders such as cystic fibrosis, hypothyroidism,
neurofibromatosis, or myopathies. The medical history should address
previous surgeries and neonatal complications, such as necrotizing enterocolitis. The character of the stools should be reviewed and include the
consistency, caliber, volume, and frequency.
In addition to plotting growth parameters and an abdominal and back
examination,acompleterectalexaminationisinstrumentalindifferentiating
functional constipation from an organic etiology. As with other systems, the
examination should begin with inspection of the perineum, looking for signs
of infection, fissures, abscesses, fistulas, ulcerations, and anal wink. The
positioning of the anal opening should be observed and documented if an
anteriorectopicanusissuspected.Therectalexamshouldbeperformedwith
the child as comfortable as possible. The tone of the anal canal should be
observed. The anal canal, although initially tight, should relax in the absence
of a stenosis, stricture, or aganglionic segment. The normal rectal ampulla
should be slightly dilated and may contain stool. The rectal ampulla should
be palpated for the presence of internal fissures, pelvic mass, or tumor.
Suggested Readings
Abi-HannaA,LakeAM.Constipationandencopresisinchildhood.PediatrRev. 1998;19(1):23–
30.
Biggs WS, Dery WH. Evaluation and treatment of constipation in infants and children. Am
Fam Physician. 2006;73(3):469–477.
Di Lorenzo C. Pediatric anorectal disorders. Gastroenterol Clin North Am. 2001;30(1):269–287.
Fitzgerald JF. Constipation in children. Pediatr Rev. 1987;8(10):299–302.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Williams & Wilkins.
More About Causes of Crying infant
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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