The Scoop on Poop, Management of Constipation by John Stutts

Report
MANAGEMENT OF THE
CONSTIPATED PATIENT IN THE
PEDIATRIC SETTING
John T. Stutts, MD, MPH
University of Louisville Department of Pediatrics
Division of Pediatric Gastroenterology
DISCLOSURE
• The speaker has been a part of the
speaker bureau for Abbott Nutrition in the
past.
LOUISVILLE.EDU
DEFINITION
• 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
LOUISVILLE.EDU
CONSTIPATION: PREVALENCE
• 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
LOUISVILLE.EDU
IN YOUR CLINIC …..
• Constipation is the #1 cause of
abdominal pain.
• If the chief complaint is abdominal pain
…. think constipation until proven
otherwise.
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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?
LOUISVILLE.EDU
FUNCTIONAL VS. ORGANIC
• 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
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FUNCTIONAL: ETIOLOGY
• 3 critical time periods
- Introduction of cereals/solids
- Toilet training
- Start of school
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FUNCTIONAL
• 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
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FUNCTIONAL
• Fecal Incontinence
- In children with constipation, there
is no clear difference in the
pathophysiology or psychology
between children with and without
fecal incontinence.9
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FUNCTIONAL: TREATMENT
• 2 phases to treatment
- Phase 1: The Cleanout
- Phase 2: Maintenance
Phase 1 is arguably the most important!
LOUISVILLE.EDU
FUNCTIONAL: CLEANOUT
OPTIONS
• 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”
LOUISVILLE.EDU
FUNCTIONAL:
MAINTENANCE OPTIONS
• 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
LOUISVILLE.EDU
FUNCTIONAL:
MAINTENANCE OPTIONS
• Osmotic
- Milk of Magnesia
≤ 1 year
2 – 6 years
7-8 years
≥ 9 years
1-2 tsp BID
2 tsp BID
1 T BID
2 T BID
- Lactulose
1 – 3 mL/kg/day
LOUISVILLE.EDU
FUNCTIONAL:
MAINTENANCE OPTIONS
• Lubricant
- Mineral Oil
• Not recommended
• Lipoid pneumonia if aspirated
• Stimulant
- Senna
≤ 2 yrs
2 – 4 yrs
5 – 6 yrs
7 – 9 yrs
≥ 10 yrs
¼ - 1 tsp BID
½ - 1 tsp BID
1 tsp BID
1 tablet BID
2 tablets BID
LOUISVILLE.EDU
HOW DO WE COME OFF
THE LAXATIVE?
• Fiber is the KEY!
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
• Wean the laxative slowly!!
LOUISVILLE.EDU
SO WHEN IS IT MORE
THAN JUST CFC?
• The question of Organic etiology…
LOUISVILLE.EDU
ORGANIC CONSTIPATION
• Organic causes are responsible for
fewer than 5% of cases of
constipation in children.
LOUISVILLE.EDU
ORGANIC CONSTIPATION
• 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
• Neuropathic
- Tethered cord
• Intestinal nerve/muscle
disorder
- Hirschsprung's disease
- Visceral myopathies
• Abnormal abdominal
musculature
- Prune-belly
- Down syndrome
- Gastroschisis
• Connective tissue
disorders
- Scleroderma
LOUISVILLE.EDU
ORGANIC CONSTIPATION
• Medications
- Opiates
- Antacids
- Phenobarbital
• Miscellaneous
- Cow’s milk protein intolerance
- Lead ingestion
- Botulism10,11
LOUISVILLE.EDU
COW’S MILK PROTEIN
ALLERGY/INTOLERANCE
• 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
LOUISVILLE.EDU
HIRSCHSPRUNG'S DISEASE
• 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
LOUISVILLE.EDU
HIRSCHSPRUNG'S DISEASE
• 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
LOUISVILLE.EDU
HIRSCHSPRUNG'S DISEASE
• Consider in the following
circumstances:
The
“classic
triad”
present
in 82%
of
cases.
- 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
LOUISVILLE.EDU
HIRSCHSPRUNG'S
DISEASE: DIAGNOSIS
• Rectal exam – The “Wine Goblet”
Explosion…
VS
H.D.
CFC
LOUISVILLE.EDU
HIRSCHSPRUNG'S
DISEASE: DIAGNOSIS
• 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.
LOUISVILLE.EDU
HIRSCHSPRUNG'S
DISEASE: DIAGNOSIS
• Rectal suction or full-thickness biopsy
═ The definitive test
-
absence of ganglion cells
-
high acetylcholinesterase
accumulation on staining
LOUISVILLE.EDU
CYSTIC FIBROSIS
• Constipation is common
• DIOS = Distal Ilial Obstruction
Syndrome
LOUISVILLE.EDU
TETHERED CORD
SYNDROME
• 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.
LOUISVILLE.EDU
TETHERED CORD
SYNDROME
• Associated signs/symptoms
- constipation
- bladder dysfunction
- weak lower extremity reflexes
• Diagnosis
- MRI of the lumbosacral spine
• Treatment
- Neurosurgical release
LOUISVILLE.EDU
ORGANIC PEARLS
• If since the neonatal period, there
has been constipation (especially
with delayed passage of
meconium)…. do an unprepped
contrast enema.
LOUISVILLE.EDU
ORGANIC PEARLS
• If a patient has recurrent UTIs,
consider constipation as an etiology
due to mechanical effects of the
distended rectum pressing on the
bladder.
LOUISVILLE.EDU
ORGANIC PEARLS
• If the patient has FTT, RAP and
constipation (+/- anemia), consider
celiac disease.
LOUISVILLE.EDU
ORGANIC PEARLS
• 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.
LOUISVILLE.EDU
ORGANIC PEARLS
• If there is impaired linear growth
and depressed reflexes…. consider
hypothyroidism.
LOUISVILLE.EDU
ORGANIC PEARLS
• If at risk of electrolyte disturbances
(metabolic abnormalities or unable
to tolerate adequate fluids)…..
check a serum Calcium.
LOUISVILLE.EDU
ORGANIC PEARLS
• If at risk for lead toxicity…. test for it.
LOUISVILLE.EDU
ORGANIC PEARLS
• 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.
LOUISVILLE.EDU
Thank you!
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Yong D, Beattie RM. Normal bowel habit and prevalence of constipation in primary school children.
Amb Child Health 1998;4:277-282.
de Araújo Sant’Anna AM, Calҫado AC. Constipation in school-aged children at public schools in Rio de
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Thompson WG, Longstreth GF, Drossman DA, et. al. Functional bowel disorders and functional
abdominal pain. Gut 1999;45:1143.
Hyman PE, Milla PJ, Benninga MA, et. al. Childhood functional gastrointestinal disorders:
neonate/toddler. Gastroenterology 2006;130:1519.
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DiLorenzo C. Pediatric anorectal disorders. Gastroenterol Clin North Am 2001;30:269.
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