multidiscipline approach for treatment of chronic constipation alex 0914

Khaled Hussein Kamel Bahaaeldin

Professor of Pediatric Surgery,

Cairo University

1/16/2015 Khaled H.K. Bahaaeeldin

Functional constipation, accounts for 3% of visits to general pediatric clinics and as many as 30% of visits to pediatric gastroenterologists.

1/16/2015 K. H Bahaaeeldin

The most common literature definition of chronicconstipation in pediatric patients is:

Stooling <3 times a week

or

Hard stools with painful passage (even with normalfrequency) during the last 2 months.


Paris Consensus on Childhood Constipation Terminology (PACCT) Group

Chronic constipation is defined as

The occurrence of two or more of the following characteristics, during the last 8 weeks:

Frequency of bowel movements less than three per week

More than one episode of fecal incontinence per week

Large stools in the rectum or palpable on abdominal examination

Passing of stools so large that they obstruct the toilet

Retentive posturing and withholding behavior

Painful defecation


Pathophysiological mechanisms that underlie childhood functional constipation are multi factorial, and not understood well.


Different factors such as

Genes, Early toilet training of children and/or difficulty in learning it Changing diet from breast feed to formula and/or liquid to

solid food, Having painful and difficult defecation, Early commencement of school, Infrequent defecation as necessity, Poor fibre dietary regime, Inadequate liquid intake, Immobilization, Psychological problems and anxiety

All can cause constipation during childhood.


Despite the fact that childhood constipation is the most common complaint in childhood gastrointestinal disease, no large, placebo controlled, randomised trials are available.


Onset of constipation frequently occurs during one of three periods:

When the infant switched from breast milk to either formula milk or introduction of solids,

When the toddler is acquiring toileting skills and finds defecation painful,

When the child starts school (they tend to avoid defecation throughout the school day).

Approximately 40% of children with functional constipation develop symptoms during the first year of life, with peak incidence during the time of toilet training, often between 2 and 4 years of age


Most children with functional faecal retention will benefit from a precise, well-organized plan. The treatment is comprehensive and has four phases including

1. Education

2. Disimpaction; removal of the faecal retention

3. Maintenance (PLAN);prevention of re-accumulation of stools through reconditioning to normal bowel habits and laxative use

4. Withdrawal of treatment.


Education Education is the start of successful management.

The child and parent are told that many children are troubled with this condition

Explain normal defecation to the child and parents.

Discuss realistic expectations for response to therapy.

Stress that months to years of treatment will be necessary.

A detailed plan eliminates the parents’ and child’s frustration and improves compliance with the prolonged treatment necessary.


Disimpaction; Isotonic enema regimen Hardened fecal matter in the colon and rectum needs to be

evacuated completely. The parents can prepare a roughly isotonic saline solution. One

teaspoon of table salt is added to every 1.5 Liters of tap water. The wash out enemas administered via a gravity assisted enema

bag and nozzle roughly one meter above the child. The parents are instructed to infuse the isotonic solution till the

child indicates discomfort, and then allowed to expel the fluid. The process is repeated using around 1-1.5 liters of fluid per session.

The regimen schedules an enema daily for one week followed by once every other day for another week. After the initial two weeks, if the child fails to pass stools for two consecutive days the parents are told to administer a rectal washout and record the episode.


Maintenance; Elements of treatment

Isotonic enema regimen

Osmotic laxatives

Dietary and bowel habits readjustments.

Fibers

Water intake

Treatment of Anal conditions


Osmotic laxatives The need to maintain adequate water intake and its

importance for the functioning of these laxatives.

Lactulose (initially starting at 1-3 ml/kg/d)

Commercial magnesium sulfate/phosphate (1-3 ml/kg/d (as 400 mg/5 ml suspension) mixture.

Two concerns ; cost & flatulence of Lactulose and palatability of the Magnesium salts.

PEG Poly Ethylene Glycol, still not available in Egypt despite having none of the disadvantages


Dietary and bowel habits readjustments. Balanced diet especially carbohydrates

The healthy diet should be balanced to incorporate vegetables, fruits, more whole grain cereals and less highly processed wheat.

Whole grain bread should be substituted for other types.

The snacks and sweets should be moderated, and are used as reward for eating healthy diets.


Fibers Children older than 2 years of age should increase

dietary fiber intake to an amount equal to or greater than their age + 5 g/day.

According to the “age + 5” rule dietary fiber intake would increase from 8 g/day at age 3 years to 25 g/day by age 20 years.

Can add bran to the child’s food (1 tbsp of wheat bran meal = 2 grams of fiber) in addition to green leafy vegetables, homemade unfiltered juices and fruits to ensure adequate dietary fiber intake.


Water intake

Age (years) Water intake

1-3 0.8-1 liter/day(roughly 4-5 cups)

4-8 1.2-1.4 liter/day(5-7 cups)

9-13 1.5-2 liter/day (6-8 cups)


Treatment of Anal conditions Perianal abscesses; incision and drainage under

general anesthesia and short course of antibiotics (ampicillin/clavulanate for 5 days).

Fistula in ano cases; fistulotomy under general anesthesia and antibiotics (ampicillin/clavulanate for one week)

Anal fissures; conservatively with local anesthetic cream prior to enema administration and defecation in toilet trained children.


SurgerySurgery, in absence of organic causes, is not easily

justifiable particularly to parents, for treatment of functional constipation in children.

However there exists a sizeable minority of cases who fail to respond to even aggressive conservative regimens.

Many modalities of surgery have been proposed; Colectomies, myectomies and colostomies. Ante grade continence enemas provide a compromise between extensive surgery and the failed conservative means


Prognosis Long-term follow-up studies revealed that 65% up to

88% of functional constipation resolve within one to four years of treatment

These wide ranges of differences are because;

No single protocol for management of Functional Constipation

and

Management necessitates a strict medical and behavioral continuous regimen that should be followed accurately and promptly by the parents.


Thank you


Find this presentation www.slideshare.net/kbahaaeldin

multidiscipline approach for treatment of chronic constipation alex 0914

Health & Medicine

pediatric patients

pediatric gastroenterologists

general pediatric clinics

cairo university1162015khaled

h bahaaeeldinthe