CONSTIPATION
DEFINITION:
The infrequent passage of stool.
EPIDEMIOLOGY:
- incidence: common
- age of onset:
- risk factors:
- see differential diagnosis
DIFFERENTIAL DIAGNOSIS:
- introduction of cow's milk
- inadequate fluid intake
- undernutrition
- high CHO and/or protein diet
- low fibre diet
2. Organic
- Diabetes Insipidus/Mellitus
- Fanconi Syndrome
- Idiopathic Hypercalcemia
2. CNS Lesions
- hypotonia (Benign Congenital Hypotonia)
- hypertonia (Cerebral Palsy)
- Infectious Polyneuritis/Poliomyelitis
- myelodysplasias
3. Gastrointestinal Anomalies
- Hirschsprung Disease
- anorectal stenotic lesions, strictures, fissures
- masses (intrinsic, extrinsic)
- anterior anal displacement
4. Others
- Hypothyroidism
- Prune-Belly Syndrome
3. Social/Medical
- "psychogenic constipation" - inadequately managed acute
problem
- coercise toilet training
- at school or camp
HISTORY:
- history of drugs (diuretics, antidepressants,
antispasmodics)
- constipation since birth (Hirschsprung Disease)
- concurrent bladder incontinence or abnormal anal tone (neurologic)
- hypothyroidism (dry skin, lethargy, slowing growing hair and
nails)
- assess height for short stature (can't touch floor)
- 99% of constipation is idiopathic
- look for a precipitating event (anal fissure)
CLINICAL FEATURES:
- constipation +/- abdominal pain
- complications:
- overflow incontinence with fecal soiling ("diarrhea")
- impaction with chronic dilatation
- UTI +/- vesicoureteral reflux
- intestinal obstruction
INVESTIGATIONS:
- abdominal x-rays may show rectal/rectosigmoid impaction and
a rectosigmoid index of < 1 (normal > 1)
2. Sigmoidoscopy
- with biopsy for Hirschrung Disease
MANAGEMENT:
- bran - oat, wheat
- psyllium - Metamucil, ProDiem
2. Osmotics
- magnesium - Milk of Magnesia, Epsin Salts
- phosphate - fleet enemas
- sugars - lactulose, sorbitol (gas, acidic stool)
- PEG - Go Litely
3. Stimulants
- phenolphthalein
- Senna, aloe, rhubarb
- castor oil
- bisacodyl
4. Stool Softeners
5. Lubricants
6. Enemas
-
Note: In the treatment of constipation in children,
there appears to be no role for stimulants, stool softeners,
lubricants, or enemas.
2. Management in Children
- draw out GI system and explain how stool is formed
- explain mechanism of constipation
- use analogy of boxcars
- use "I gotta go valve" and "not now valve"
- explain the 3 steps needed to correct the constipation
- no quick fix and in for the long haul with follow ups
- compliance is vital so fun foods are important
- parents, doctor, and child must have a health attitude
- may keep a stool diary to be reviewed on follow-up
3. Phase I - Clean Out Phase:
- to empty the bowel from above or below
- 2-4 litres over 2-3 days
- mix with Tropical Punch Kool-aid
- 5 scoops of Kool-aid to 1 litre of PEG
- will come out the same colour as flavoured PEG
- PEG is not thirst quenching so child will continue to
drink throughout the day
- try to buy in 1 litre jugs
- may also mix with frozen orange juice
- will be an initial liquid phase -> solid phase -> then
another liquid phase or
2. Hypertonic Phosphate Enemas
- three times over 36-48 hours
4. Phase II - Maintenance (Training) Phase:
- to allow the bowel to return to normal size
- 1 tbsp. po bid -> qid
- enough to give 1-2 loose stools per day everyday x 1
month
- may start during initial Clean Out Phase
- give between meals to avoid fat-soluble vitamin
absorption problems
- comes in many different flavours and
2. Oat Bran
- 2/3 cup oatbran + 1 cup of water
- microwave at 100% x 2 min + at 20% x 10 min
- add brown sugar, milk, strawberry cow, peaches, etc. or
3. Metamucil plain or ProDiem plain
- 1 tbsp. po od
- add Metamucil to peanut butter and jam sandwiches,
soups, mashed potatoes
- may make homemade jams with psyllium instead of pectin
- sprinkle ProDiem on Ice Cream or puddings
- sit on toilet with proper foot support for 5 minutes
after breakfast and after the evening meal (gastrocolic
reflex)
5. Phase III - Tapering Phase:
- reduce MM by 20% monthly
- follow-up:
- should see improvement in appetite, activity and school
performance
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