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Chronic Constipation -Dr. Vishnu Biradar
- 1. Chronic Constipation Dr.VishnuBiradar Cons. Pediatric Gastroenterologist Pune
- 2. What is constipation? NASPGAN (2006): Defined as a delay or difficulty in defecation, present for two or more weeks and sufficient to cause significant distress to the patient. Stool frequency of < 3 per week is also defined as constipation
- 3. Rome III criteriaConstipation infants and children up to 4 yrs One months of at least 2 of the followings ◦ 2 or fewer defecations per week ◦ At least 1 episode per week of incontinence after acquiring toileting skills ◦ History of excessive stool retention ◦ History of painful or hard bowel movements ◦ Presence of a large fecal mass in the rectum ◦ History of large diameter stools that may obstruct the toilet Accompanying symptoms ◦ Irritability, decreased appetite and / or early satiety. ◦ The accompanying symptoms disappear immediately following passage of a large stool.
- 4. Classification of constipation I. Depending upon the age of onset Congenital constipation (Since birth) Acquired constipation
- 5. Classification of constipation II. Depending upon the duration Acute constipation (2 weeks to 3 months) Chronic constipation (> 3 months) Mild - No megarectum/megacolon or impaction - No encopresis Severe – megarectum / megacolon or impaction - Associated with encopresis
- 6. Etiology of chronicconstipation Congenital Anorectal defects Anal stenosis / atresia Imperforate anus Anterior displaced anus Neurogenic Myelomeningocele Spina bifida Colonic neuropathies Hirschsprung’s disease Intestinal neuronal dysplasia Colonic defects Colonic atresia Short colon Aquired Functional 90-95% Anal lesions Fissures, abscesses, strictures Neurological conditions Cerebral palsy, MR Lesions of spinal cord Metabolic Hypokalemia,hypercalcemia, Endocrine Hypothyroidism, DM Hyperparathythroidism Drug induced Antimotility, anticholinergics Codeine, antacids
- 7. What is normal? Stool frequency decreases from a mean of 4/day in the first week of life to 1.7/day by the age of 2 years In this period, stool volume increases 10 fold, water content consistent approximately 75% Intestinal transit time from mouth to rectum increases from 8 hours in the first month of life to 16 hours by 2 years of age to 26 hours by the age 10.
- 9. How does itwork ? Sigmoid colon acts as storehouse of faeces When more than 15 cc of stool enters the normal rectum, relaxation of internal sphincter Relaxation of internal sphincter allows the stool to reach the external anal sphincter and the urge to defecate is signaled If the child relaxes the external anal sphincter, squats to straighten the anorectal canal, and increases intra-abdominal pressure the rectum is evacuated of stool
- 10. Pathogenesis Painful defecation Voluntary withholding Prolonged fecal stasis Re-absorption of fluids in size & consistency More pain
- 11. Why it occurs? Diet – low in fiber Unsuccessful toilet training Logical response to painful stools (anal inflammation from fissures, perianal infection, perianal abscess) Threatening event such as a television show, birth of a sibling Desire to avoid defecation in a strange toilet when away from home. Some toddlers and older children are too distracted to evacuate (mainly ADHD).
- 12. Red flag signs- History Onset < 1 year Delayed passage of meconium Absence of withholding, soiling Bladder dysfunction Non-GI symptoms No response to Rx
- 13. Red flag signs- Exam FTT Abdominal distension Pilonidal sinus Lack of lumbosacral curve Patulous anterior anus Empty rectum on PR Absent anal wink, cremasteric reflex Lower limb weakness
- 14. Constipation Vs Hirschsprung’s HD Constipation Age Since birth or within 1 to 2 months of age Starts after 1 year of age Soiling Unusual Common Straining at defecation No straining Present Ability to pass large bulky stool Unusual Common Pain and bleeding on defecation Unusual Present Anal fissures Absent Present Rectal exam Rectum empty Full of hard stool Barium enema Transitional zone Dilatation from anal canal upwards Rectal biopsy Ganglion cells absent Ganglion cells present
- 15. Goal of therapy Evacuation of stool without pain
- 16. Treatment Precise,well-organized plan:to clear fecal retention,prevent future retention & promote regular bowel habits. 1.Disimpaction: enema or lavage solutions 2.Maintenance: prevention of re-accumulation I. Diet II. Toilet training III. Laxative 3. EDUCATION of PARENTS
- 17. Phase I :Complete Disimpaction Impaction – palpate fecal mass, dilated rectum full of hard stools on PR, X ray abdomen No management plan will succeed if complete evacuation is not achieved initially Without disimpaction, laxatives will cause increase in overflow incontinence, pain, bloating, acute abd Oral / rectal / surgical routes of disimpaction
- 18. Phase I :Complete Evacuation or Disimpaction Oral route – PEG soln – 1.5gm/kg/day x 3-5 days 25ml/kg/hr till clear fluid (hosp) - Mineral oil – 15-30ml/year (max 240ml) x 2-3 days (not for infants) Lactulose, senna, bisacodyl ??? Non-invasive but slower
- 19. Phase I :Complete Evacuation or Disimpaction Rectal route ◦ Glycerin suppository (infants) ◦ Phosphate (6ml/kg/day), saline enemas x 2-5 days ◦ Avoid tap water, soap water enemas Faster but invasive
- 20. Phase II :Maintenance Therapy Aim is to prevent impaction and allow the distended colon to return to normal calibre and tone. Laxatives Diet Behavioral modification
- 21. Agents Dosages Sideeffects Lactulose /Lactitol /Sorbitol /Mannitol 1-3 ml /kg/day in 2 doses Bloating, cramps, diarrhea, Safe Magnesium hydroxide 1-3 ml /kg/ day in 2 doses of 400mg/5ml con. Hypermagnese mia, hypophosphate mia and secondary Polyeythylene hypocalcemia glycol (PEG) 3350 1gm/kg/day in 2 doses Nausea, vomiting, cramps and diarrhea Mineral oil (liquid paraffin) 1-3 ml/kg/ day in 1-2 doses Aspiration risk Lipoid pneumonia, nausea, palatable if chilled Safe
- 22. Laxatives 3-24months of therapy Avoid frequent weaning of laxatives Adjust dose individually Milk of magnesia, lactulose, PEG, mineral oil Avoid bisacodyl, senna, phenolpthalein (rescue Rx) Cisapride
- 23. Diet in themanagement Breast feeding Reduce constipating foods such as dairy products, bakery products, and starches. Additional fiber has no value when colorectal tone is diminished in the child who has active functional fecal retention. In the second phase, when tone is being restored, additional fiber is of great value to improve the “efficiency” of evacuation
- 24. Dietary fiber It is a non-starch polysaccharide - can be soluble in water or insoluble Insoluble fiber swells upon contact with water and stimulates the peristalsis and increase the transit time. No “DRA” for fiber in children Recommended daily fiber intake is 8+ age in years in gms
- 25. Behavioral modification Regular sitting on toilet, 3 times daily after meals for 5-10mins Childs feet on foot rest Stool diary Reward system
- 26. Follow-up schedule Monthly:till regular bowel movement is achieved: Check stool diary,physical and rectal examination Laxative dose adjusted: target (1-2 soft stool/day) 3 monthly for next 2 yrs.: Continue same dose of laxative for at-least 3 months (distended bowel to regain its function) and then slow tapering (Early withdrawal of laxative is the commonest cause of recurrence ) Yearly follow-up.
- 27. OUTCOME Excellentresults 45-100% for 2 months to 3 years Moderate improvement 20-30% Failure 25-35% 30% of children continue to be constipated during adolescence.
- 28. In infants ….. Exclude organic causes like HD, HT anorectal problems, drugs, etc Faulty feeding Do not use mineral oil stimulant laxatives Avoid enemas for disimpaction Sorbitol, lactulose are safe PEG is safe
- 29. Thank you .. .