Constipation – It’s a dirty job, …

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.