Constipation – It’s a dirty job, …

 

Dirty Jobs

We evaluate a lot of patients with abdominal pain. We are actively search for appendicitis and get a slight sense of self-satisfaction when we diagnose it. Conversely, constipation is many times the default diagnosis in the patient with unclear etiology of abdominal pain – and we have to be honest and admit, that it kind of irks us. But before you dismiss this as “he is just really full of it,” be mindful of a few Morsels:

Constipation is common!

  • Estimated that ~5-10% of all pediatric patients have constipation⇒ 2nd most common reason for referral to pediatric GI (~25% of all of their business)

Constipation as consequences!

  • Things that we might not appreciate initially but are very important to the patients and their families.
    • For one… it hurts
    • This pain often leads to medical visits and loss of days of school (and work for parents)
    • May become socially disabling
    • Hard stools and excessive straining can lead to Anal Fissures and Hemorrhoids (which worsen the problem)
    • May also produce rectal prolapse (a very scary phenomena for the family)
    • Fecal empaction can produce encopresis (very socially disabling)
    • Colonic distention from the hard stool can also lead to complications in itself.

Constipation has Organic Causes (it all isn’t just Functional Constipation)

  • Although ~95% of constipation is functional… you don’t get paid for the 95% diagnosis (Grandma can make that call)… you get paid to not miss the other 5%
  • Consider some of these entities when you are diagnosing constipation
    • Drugs (anticholinergics, antidepressants, antihypertensives, opiates, IRON)
    • Hirschprung disease [see previous Morsel] (and other colonic neuropathies)
    • Neurogenic (Cerebral Palsy, Spina Bifida, etc)
    • Endorcrine (DM, Hypothyroidism, Hyperparathyroidism)
    • Metabolic (Cystic Fibrosis, Celiac Disease, Electrolyte disturbances)
    • Anatomic (Abscesses, fissures, imperforate anus, anterior displaced anus, strictures from IBD)

 

  • Odds will be in your favor that it is Functional Constipation… but focus on some key points to help increase your ability to detect the Organic Causes
  • History that increases the likelihood of an organic cause (document lack or presence of)
    • Constipation since birth
    • Delayed passage of meconium
    • Vomiting
    • Hematochezia
    • Melena
    • Urinary Retention
    • Failure to Thrive
  • Physical Exam (document some of the following to show that you’ve considered more than just Functional Constipation):
    • Sacral Dimple? (Associated with Spina Bifida)
    • Anal Wink?
    • Abdominal Distension?
    • Fecal Mass (often palpable in the LLQ or suprapubic area)
    • Anal stenosis?
    • Perianal Skin tags? (Associated with IBD)
    • Perianal Strep Infection?? (see previous Morsel)
    • Neuro Exam! Normal DTRs? Saddle Anesthesia?
    • THE RECTAL EXAM
      • Generally not necessary.
      • It most often does not add to the diagnosis.
      • It will be invasive and threatening… and potentially exacerbate an already significant problem the patient has in that general region.
      • When to perform?
        • In cases where you are more concerned for organic casues or unclear.
        • To assess rectal tone – although Anal Wink is pretty good for this also!
        • To assess consistency and amount of stool
          • Function Constipation – Often Large Hard Stool present with dilated ampulla
          • Colonic Neuropathy – Narrow ampulla with scant stool present that is soft.

Treatment for Constipation

  • Treatment of Function Constipation requires a Team Approach. We start the process in the ED, but in order to be successful, the patient needs close follow-up and family education.
  • Consider your therapy as being a part of al long process and describe it that way to set the family’s expectations. [There are many medications (I’ll refer you to the references which have nice tables… but mention a few here)]
    • Disimpaction (for those with h/o stool withholding and fecal mass present)
      • Oral, rectal, or combination are effective
      • Rectal enemas may not be the best 1st option as they may exacerbate the psychologic problem
      • Glycerin suppositories (< 6yrs – one infant suppository)
      • Milk of Magnesia (<2yr – 0.5 mL/kg/Day; 2-5yrs – 5-15mL/Day; 6-12yrs – 15-30ml/Day)
      • Mineral Oil (>4yrs – 15-30 mL/ year of age)
      • MIRALAX (<18mos – 0.78g/kg/Day; 2-11yr – 8.5g/4 oz water; >12yr – 17 g/8 oz water)
    • Maintanence (prevent the reaccumulation of stool)
    • EDUCATION
      • Increase fluid intake, fruits and vegetables, whole grains and fiber [number of grams/Day = kid’s age +5] (Popcorn is an easy way to increase fiber)
      • Behavioral modification (sit on toilet for 10 minutes after each meal, positive reinforcement, etc)
      • Medications (see above and references) – Mineral Oil is effective!
      • Rescue Medication (if there has been no BM in 2 or 3 days) – Stimuant laxative (Senna)

 

Montgomery DF, Navarro F. Management of Constipation and Encopresis in Children. Journal of Pediatric Health Care 2008; 22: 199-204.

Bulloch B, Tenenbein M. Constipation: Diagnosis and management in the pediatric emergency department. Pediatric Emergency Care. 2002; 18(4): 254-258.

Youssef NN, DiLorenzo C. Childhood Constipation. J. Clin Gastroenterol 2001; 33(3): 199-205.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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