john t. stutts, md, mph university of louisville department of pediatrics division of pediatric...
TRANSCRIPT
THE SCOOP ON POOP
MANAGEMENT OF THECONSTIPATED PATIENT IN THE PEDIATRIC SETTINGJohn T. Stutts, MD, MPHUniversity of Louisville Department of Pediatrics
Division of Pediatric Gastroenterology
L O U I S V I L L E . E D U
• The speaker has been a part of the
speaker bureau for Abbott Nutrition
in the past.
DISCLOSURE
L O U I S V I L L E . E D U
• Constipation: “A delay or difficulty in defecation, present for ≥ 2 weeks and sufficient to cause significant distress to the patient.”1
• Encopresis: “The involuntary loss of formed, semi-formed, or liquid stool in the child’s underwear, in the presence of functional constipation after the child has reached a developmental age of 4 years.”1
DEFINITION
L O U I S V I L L E . E D U
• As many as 3% of visits to the primary
care physician.1
• As many as 25% of visits to the
pediatric gastreoenterologist.1
• 16 – 37% of otherwise healthy 4 to 11
year old children have constipation.2-6
CONSTIPATION: PREVALENCE
L O U I S V I L L E . E D U
• Constipation is the #1 cause of
abdominal pain.
• If the chief complaint is abdominal
pain …. think constipation until
proven otherwise.
IN YOUR CLINIC …..
L O U I S V I L L E . E D U
IN YOUR CLINIC …..
• A question not to ask:- Is your child constipated?
• A better question that will
give you a clearer picture:- How many days does your child skip between bowel movements?
L O U I S V I L L E . E D U
• Functional Constipation- An umbrella term describing persistent, difficult, infrequent or seemingly incomplete defecation without evidence of a primary anatomic or biochemical cause.7
- Accounts for greater than 95% of constipation-related symptoms in children and infants, except those during the neonatal period when organic causes are more likely.7
FUNCTIONAL VS. ORGANIC
L O U I S V I L L E . E D U
• 3 critical time periods- Introduction of cereals/solids
- Toilet training
- Start of school
FUNCTIONAL: ETIOLOGY
L O U I S V I L L E . E D U
• Infant Dyschezia- At least 10 minutes of straining and/or crying before successful passage of soft stool in an otherwise healthy infant < 6 mos of age.
- The symptom is due to failure to relax the pelvic floor during the defecation effort and resolves spontaneously.8
FUNCTIONAL
L O U I S V I L L E . E D U
• Fecal Incontinence- In children with constipation, there is no clear difference in the pathophysiology or psychology between children with and without fecal incontinence.9
FUNCTIONAL
L O U I S V I L L E . E D U
• 2 phases to treatment- Phase 1: The Cleanout
- Phase 2: Maintenance
Phase 1 is arguably the most important!
FUNCTIONAL: TREATMENT
L O U I S V I L L E . E D U
• Enemas- Phosphate Enemas
Adult (≥ 3 yoa)Pediatric (< 3 yoa)
- SMOG (Saline, Mineral Oil, Glycerin)- Milk and Molasses
• Magnesium Citrate- 1 oz per year of age to a max of 10oz- once daily x 3-6 days- not for infants/toddlers
• Polyethylene glycol- “multiple doses” vs “the gallon”
FUNCTIONAL: CLEANOUT OPTIONS
L O U I S V I L L E . E D U
• Osmotic- Polyethylene glycol (1 capful = 17 grams)
3 yoA ½ capful Q day
6 yoA ½ capful BID
*10 yoA 1 capful BID
13 yoA 1 – 1 ½ capfuls BID
18 yoA 1 – 2 capfuls BID
FUNCTIONAL: MAINTENANCE OPTIONS
L O U I S V I L L E . E D U
• Osmotic- Milk of Magnesia
≤ 1 year 1-2 tsp BID2 – 6 years 2 tsp BID7-8 years 1 T BID≥ 9 years 2 T BID
- Lactulose1 – 3 mL/kg/day
FUNCTIONAL: MAINTENANCE OPTIONS
L O U I S V I L L E . E D U
• Lubricant- Mineral Oil
• Not recommended• Lipoid pneumonia if aspirated
• Stimulant- Senna
≤ 2 yrs ¼ - 1 tsp BID2 – 4 yrs ½ - 1 tsp BID5 – 6 yrs 1 tsp BID7 – 9 yrs 1 tablet BID≥ 10 yrs 2 tablets BID
FUNCTIONAL: MAINTENANCE OPTIONS
L O U I S V I L L E . E D U
• Fiber is the KEY!
• Wean the laxative slowly!!
HOW DO WE COME OFF THE LAXATIVE?
AGE DOSE
1 – 3 years 15 grams/day
4 – 8 years 20 grams/day
9 – 12 years 25 grams/day
≥ 13 years 30 grams/day
L O U I S V I L L E . E D U
•Organic causes are
responsible for fewer than 5%
of cases of constipation in
children.
ORGANIC CONSTIPATION
L O U I S V I L L E . E D U
• Anatomic- Anal stenosis- Imperforate anus- Anteriorly displaced anus- Pelvic mass (sacral
teratoma)
• Metabolic- Hypothyroidism- Hypercalcemia- Hypokalemia- Cystic Fibrosis- Diabetes Mellitus- Celiac disease- MEN type 2B
ORGANIC CONSTIPATION
• Neuropathic- Tethered cord
• Intestinal nerve/muscle disorder
- Hirschsprung's disease- Visceral myopathies
• Abnormal abdominal musculature
- Prune-belly- Down syndrome- Gastroschisis
• Connective tissue disorders
- Scleroderma
L O U I S V I L L E . E D U
• Medications- Opiates- Antacids- Phenobarbital
• Miscellaneous- Cow’s milk protein intolerance- Lead ingestion- Botulism10,11
ORGANIC CONSTIPATION
L O U I S V I L L E . E D U
• 0.3 – 7.5% of normal infants
• Think about this in the infant who has
constipation in association with rhinitis,
dermatitis or bronchospasm
• Options: - Dairy elimination for the breast feeding
mother- Casein Hydrolysate formulas- Elemental amino acid-based formulas12,13
COW’S MILK PROTEIN ALLERGY/INTOLERANCE
L O U I S V I L L E . E D U
• More than 90% of normal
infants, but only 10% of infants
with Hirschsprung's disease,
pass meconium within the first
24 hours of life.14
HIRSCHSPRUNG'S DISEASE
L O U I S V I L L E . E D U
• A motor disorder of the colon caused
by failure of neural crest cells to
migrate completely during colonic
development.
• The result … the affected segment of
the colon fails to relax causing a
functional obstruction.14
HIRSCHSPRUNG'S DISEASE
L O U I S V I L L E . E D U
• Consider in the following circumstances:
- Delayed passage of meconium (after 48 hours of life)
- Abdominal distention- Vomiting- Onset of symptoms in the first week of life
- A transition zone on contrast enema14
HIRSCHSPRUNG'S DISEASE
The “classic triad” present in 82% of cases.
L O U I S V I L L E . E D U
• Rectal exam – The “Wine Goblet” Explosion…
HIRSCHSPRUNG'S DISEASE: DIAGNOSIS
VS
H.D. CFC
L O U I S V I L L E . E D U
• Unprepped contrast enema- If H.D. present, a transition zone will be seen ~ 70% of the time.
• Anorectal manometry- When the rectal balloon is inflated,
reflex relaxation of the internal anal sphincter fails to occur.
HIRSCHSPRUNG'S DISEASE: DIAGNOSIS
L O U I S V I L L E . E D U
• Rectal suction or full-thickness biopsy
═ The definitive test- absence of ganglion cells
- high acetylcholinesterase accumulation on staining
HIRSCHSPRUNG'S DISEASE: DIAGNOSIS
L O U I S V I L L E . E D U
• Constipation is common
• DIOS = Distal Ilial Obstruction
Syndrome
CYSTIC FIBROSIS
L O U I S V I L L E . E D U
• What is it exactly?
Stretch-induced dysfunction of the caudal spinal cord and conus caused by attachment of the filum terminale to inelastic structures caudally.
TETHERED CORD SYNDROME
L O U I S V I L L E . E D U
• Associated signs/symptoms- constipation- bladder dysfunction- weak lower extremity reflexes
• Diagnosis- MRI of the lumbosacral spine
• Treatment- Neurosurgical release
TETHERED CORD SYNDROME
L O U I S V I L L E . E D U
• If since the neonatal period,
there has been constipation
(especially with delayed
passage of meconium)…. do an
unprepped contrast enema.
ORGANIC PEARLS
L O U I S V I L L E . E D U
• If a patient has recurrent UTIs,
consider constipation as an
etiology due to mechanical
effects of the distended rectum
pressing on the bladder.
ORGANIC PEARLS
L O U I S V I L L E . E D U
• If the patient has FTT, RAP and
constipation (+/- anemia),
consider celiac disease.
ORGANIC PEARLS
L O U I S V I L L E . E D U
• If there is spinal dysraphism or
neurological impairment of the
lower extremities and/or daytime
wetting in association with
constipation, obtain an MRI of the
lumbosacral spine.
ORGANIC PEARLS
L O U I S V I L L E . E D U
• If there is impaired linear
growth and depressed
reflexes…. consider
hypothyroidism.
ORGANIC PEARLS
L O U I S V I L L E . E D U
• If at risk of electrolyte
disturbances (metabolic
abnormalities or unable to
tolerate adequate fluids)…..
check a serum Calcium.
ORGANIC PEARLS
L O U I S V I L L E . E D U
• If the H & P remains equivocal
for etiology, don’t be afraid to
get a KUB …. but remember the
readings can be inconsistently
interpreted. So, don’t be afraid
to look at the film yourself.
ORGANIC PEARLS
REFERENCES1. Baker SS, Liptak GS, Colletti RB, et.al. Constipation in infants and children: evaluation and
treatment. J Ped Gastro Nutr 1999;29(5):612-626.2. Issenman RM, Hewson S, Pirhonen D, et. al. Are chronic digestive complaints the result of
abnormal dietary patterns? Am J Dis Child 1987;141(6):679-682.3. Yong D, Beattie RM. Normal bowel habit and prevalence of constipation in primary school
children. Amb Child Health 1998;4:277-282.4. de Araújo Sant’Anna AM, Calҫado AC. Constipation in school-aged children at public
schools in Rio de Janeiro, Brazil. J Ped Gastroenterol Nutr 1999;29(2):190-193.5. Zaslavsky C, Ávila EL, Araújo MA, et. al. Constipaҫão intestinal da infância – um estudo de
prevalência. Rev AMRIGS 1988;32:100-102.6. Maffei HVL, Moreira FL, Oliveira WM, et. al. Constipaҫão intestinal em escolare. J Pediatr
1997;73:340-344.7. Thompson WG, Longstreth GF, Drossman DA, et. al. Functional bowel disorders and
functional abdominal pain. Gut 1999;45:1143.8. Hyman PE, Milla PJ, Benninga MA, et. al. Childhood functional gastrointestinal disorders:
neonate/toddler. Gastroenterology 2006;130:1519.9. Benninga MA, Bϋller HA, Heymans HS, et. al. Is encopresis always the result of
constipation? Arch Dis Child 1994;71:186.10. DiLorenzo C. Pediatric anorectal disorders. Gastroenterol Clin North Am 2001;30:269.11. Thiessen PN. Recurrent abdominal pain. Pediatr Rev 2002;23:39.12. Magazzu G, Scoglio R. Gastrointestinal manifestations of cow’s milk allergy. Ann Allergy
Asthma Immunol 2002;89:65.13. Turunen, et al. Lymphoid hyperplasia and cow’s milk hypersensitivity in children with
chronic constipation. J Pediatr 2004;145:606.14. Lewis NA, et. al. Diagnosing Hirschsprung’s disease: increasing the odds of a positive
rectal biopsy result. J Pediatr Surg 2003;38:412.