CONSTIPATION

as many as 20% of children < 5 years of age Assessment   History age of onset, dietary history associated symp...

• as many as 20% of children < 5 years of age
  

Assessment

 

History

1. age of onset, dietary history
2. associated symptoms: abdo pain, encopresis, overflow diarrhea

 

Physical exam

1. examine lower back for evidence of occult cord lesion (NTD)
2. abdominal exam
3. rectal exam 

• most often diet-related with no specific disease 
• Hirschsprung's disease

 

Functional Constipation 

 

1. 99% of cases of constipation
2. lack of bulk or fibre in diet or change in diet
3. poor fluid intake 
4. in children, can occur during toilet training, or due to pain on defecation, stool witholding
5. in infants, often when introducing cow's milk
6. after breast milk 

Complications

1. anal fissures and pain -----> withhold passing stool
   ----> chronic dilatation and overflow incontinence,
2. encopresis = Pain Retention Cycle

 

Treatment

 

1. ïncrease fluids, increase dietary fibre
2. may need mineral oil, laxatives
3. appropriate toilet training technique

Specific Organic Disorders

1. Hirschsprung's Disease (congenital aganglionic megacolon)

 

1. rectosigmoid in 75% of cases
2. incidence: M:F=3:1, 1/5 000 live births
3. associated with Down syndrome

 

Clinical features

1. severity depends on length of involvement
2. no meconium within first 24 hours
3. palpable stool on abdominal exam with empty rectum on DRE
4. intermittent diarrhea, BM only with rectal stimulation
5. constipation
6. abdominal distention
7. vomiting
8. FTT

 

complications

1. enterocolitis: may be fatal, peak incidence 2-3 months of age
2. toxic megacolon and perforation

 

Diagnosis

1. barium enema: proximal dilatation due to functional obstruction, empty rectum
2. manometric studies: may have false positives
3. rectal biopsy: definitive diagnosis (absent ganglion cells) 

Treatment

 

1. nonsurgical if short segment
2. surgery: colostomy and re-anastomosis

2. Other

 

1. intestinal obstruction
2. endocrine
   • hypothyroidism
   • diabetes mellitus
   • hypercalcemia 
3. neurogenic bowel (i.e. spina bifida) 
4. anal fissure/stricture/stenosis 
5. collagen vascular disease 
6. drugs: lead, chemotherapy, opioids