chronic constipation update in managment.ppt8

7/23/2019 Chronic Constipation Update in Managment.ppt8

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ChronicConstipation:

Update inManagement

Abdulwahab Telmesani

FRCPC,FAAP

Faculty of Medicine andMedical Science

Umm Al-Qura Uniersity



Chronic constipation

3% of the visits to general pediatrics.

25% of the visits to pediatrics G.I.



Defnition

Infrequent stool

Hard stool Large stool



Defnition

NASGAN!

A dela" or difficult" in defecationpresent for 2 or #ore $ees and

sufficient to cause significant distress

to the patient.



Normal requency o bowelmovement



Epidemiology:

&he prevalence of childhood constipation

in the general population ranged fro#

'.(% to 2).*%

Maarte M! et al

"m # $astroenterol %&&'



Epidemiology:

constipation correlated $ith lo$ #aternal

education+ fe#ale se,+ living in a large

co##unit" and having no older si-lings.

#(N") * et! al! "cta +,diatrica-%&&'



E.clusive breast edbabies

In conclusion+ infrequent -o$el #ove#ents in

"oung infants fed e,clusivel" -reast #il can

-e a har#less pheno#enon that can easil"

diagnosed -" histor" and careful e,a#ination

of the infant.

/on 0o Choe et al Eur # +ediatr1%&&23



*unctional constipation in infants: a ollow4up study

e conclude that #ost infants $ith severe

constipation evaluated at a tertiar" center arerecovered after * #onths. /arl" therapeutic

intervention #a" -eneficiall" contri-ute to the

resolution of constipation. van den 5erg MM et al # +ediatr

%&&6



7rend in amily 8 $enetic

ro#inent fa#il" histor" of constipation.

Identical t$ins have * ti#es foldspossi-ilit" than non identicals.



Chronic constipation

0unctional 1 non organic is #ost

co##on

rganic is rare e,cept in infanc"4



*unctional 8 non organicconstipation

hat cause it 1 start it



*unctional 8 non organicconstipation

Inappropriate toilet training

Anal fissure 1 Anusitis

Avoidance of response to nature call

Inconvenient 1 unco#forta-le places

6ehavioral

7icious c"cle of retention develop#ent.



Encopresis:

Incontinence of stool of non organic

rigin rare -efore 3 "ears4



(rganic Causes o

Chronic constipation:

hat are the causes



Chronic constipation inchildren: (rganic disorders

are a maor cause

A significant nu#-er of the children $ith

chronic treat#ent8resistant constipation #a" have organic causes slo$ colonic transit and

outlet o-struction4 and suggests ne$

approaches to the #anage#ent of children $ith chronic treat#ent8resistant constipation.

59 )outhwell et al J. Paediatr. Child Health1%&&63



Stool $ithholding presenting as a cause of

non8epileptic sei9ures

"nthony Cohn

DevelopmentalMedicine and Child Neurology; (ct %&&6



chronic constipation andood hypersensitivity

An increasing nu#-er of reports suggest a

relationship -et$een refractor" chronicconstipation and food allerg" in children.

CARRCC! " #. !ACN

"limentary +harmacology 7herapeutics %&&'



Evaluation



Evaluation

Histor".

h"sical e,a#ination.



0istory::econiu# passage.

0requenc" of -o$el #ove#ent.

;iet. School 1 travel.

ainful defecation.

0a#il" histor". 0&&.

<logging of the co##ode.



+hysical e.amination:

Gro$th

A-d. ;istention

0ecal #ass felt on a-d. e,a#.

=ectu# full of stool

0ecal soiling.

Anogenital inde,



"nogenital inde.:

;istance in centi#eters!

fro# the vagina or scrotu# to the anus

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

fro# the vagina or scrotu# to the cocc",.

0e#ales! '.3) ? '.')+

:ales! '.5* ? '.2.



+hysical e.amination:

Anal fissure 1 anusitis.

Signs of trau#a a-use4.

Signs of spinal defects spina -ifida4

Neurological assess#ent of L.L. and

anal $en



Myelomeningocele



)pina bifda



7ethered cord syndrome



Neurofbromatosis



;nvestigations



;nvestigations:

Non is required routinely.



;nvestigations:

Stool analysis ??? Whyyyy



;nvestigations:

lain a-do#inal @ =A. o-ese child

or refusing e,a#4

Lu#-osacral @ =A 1 :=I

6a. /ne#a

=ectal -iops".

&B+ Na+ C+ s#olalit".



;nvestigations:

Anorectal #ano#etr".

Anal sphincter /:G.;efecograph".

<olorectal transit stud".



Management



Management:

Evaluation and Treatment of Constipation in

Infants and Children: Recommendations ofthe North merican Society for !ediatric

"astroenterolo#y$ %epatolo#y and Nutrition

D<linical ractice GuidelineE # +ediatr $astroenterol Nutr %&&' )ep< =ol!

2> 1>3- pp! e?4?>!



Management:

/ducation.

;isi#paction.

:aintenance.

6ehavioral #odification.



Education:

/ducate the fa#il" and the child if

possi-le!

athoph"siolog"

&hat incontinence is not $illful.

Fse dra$ings to e,plain.



Disimpaction:

0ecal i#pact evacuation!

hosphate ene#a fleet ene#a4ral #edication e.g. #ineral oil

paraffin oil4+ pol"eth"lene gl"col

/G335'4 or -oth



Maintenance:

:ieral oil paraffin oil4 83 #l1g1da"

ol"eth"lene gl"col /G 335'4

electrol"te free g1g1da"



Maintenance:

Lactulose+ :g h"dro,ide+ Sor-itol+

others have -een usedn and off la,atives e.g. Senna



Maintenance:

In case of anal fissure+ appl"

petroleu# gel to anal areafrequentl"



Maintenance:

Increase dietar" fi-ers

rune JKM

ear Ouice

Apple Ouice



" comparative study: 7he e@cacyo

liquid para@n and Aactulose inmanagement o chronic unctionalconstipation

Liquid paraffin is #ore effective in the treat#ent

of children $ith constipation.

N"*;/E U9$"NC; et al

Pediatrics !nternational 1%&&63



5ehavioral modifcation:

=egular toilet ha-it after #eals4

Ceep diar" and record use calendarand stars4

:otivation avoid negative co##ents4

Consultation with



Consultation withspecialist:

ediatric G.I. <eliac disease+ etc.4

/ndocrine h"poth"roidis#+ etc.4

Nephrolog" dia-etes insipidus4

ediatric surger" Herschsprung4



5ioeedbacB:

Lac of coordinated rela,ation of

e,ternal sphincter $hile defecationn #ano#etr"



5ioeedbacB:

&here is no evidence that -iofeed-ac

training adds an" -enefit to conventional

treat#ent in the #anage#ent of

functional fecal incontinence in children

5raelli- M et al

7he Cochrane

Aibrary- Copyright %&&'



)urgical 7reatment:

Anorectal #"ecto#"

&he :alone appendicocecoso#" forretrograde irrigation4

Aong47erm (utcome o



Aong 7erm (utcome o*unctional Childhood

Constipation <hildhood constipation appears to -e a

predictor of I6S in adulthood.

)eema han et al Digestive

Diseases )ciences< #an %&&



&han "ou



%irschsprun# &isease

'requency In the (S: Hirschsprung disease occurs

in appro,i#atel" per 5''' live -irths.

!athophysiolo#y: Hirschsprung disease results fro# the a-sence of paras"#pathetic ganglion

cells in the #"enteric and su-#ucosal ple,us

of the rectu# and1or colon.

chronic constipation update in managment.ppt8

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