constipation smt vi 2010

7/29/2019 Constipation Smt VI 2010

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Prof.DR.Subijanto,MS,dr,SpA(K)

DR.Reza Ranuh,dr,SpA(K)

Alpha Fardah,dr,SpA

Andy Darma, dr, SpA

Dept.of Child Health Soetomo Hospital Medical Faculty

Airlangga University

Kuliah Semester VI - 2010


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3% of all general pediatric visits

10-25% cases in pediatric gastroenetrology

Prevalence : 0.3% - 28% ( young age, > functionalconstipation )

Male : 70.3% - female: 29.63% ( Pitono Soeparto1991 )

Chronic constipation : 15.05% Hirschsprungs ;39.78% megacolon with normal hystopatology

35.48% : normal radiographs 2.15% : intestinal hypomotility


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Delay or difficulty in

defecation : > 2 weeks

Causing significan

distress 90% functional

constipation

3% of all pediatrict

clinical practice 10 25% pediatric

gastroenterology


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Intestinal Pseudo-obstruction Hirschprung disease Anal stricture/stenosis Anterior dislocation of

the anus Meconium ileus

equivalent (CF) Celiac disease

Metabolic Hypothyroidism Hypopotasium Hypercalcemia Dehydration

Drugs Narcotics Antidepressants Lead

Neuromuscular Infant botulism Spinal cord lesion


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Meconeum first 24hours 87%

Meconeum first 48hours 99%

Infant week I : 1 9

x/day Infant week II : 1 7

x/day 37 mo : complete bowel

control

Pre-school age : 3 x/d ; 3x/week.

Normal consistency. Normal size.


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Stool in rectum

Rectal

distension

Temporary reflex

relaxation of the IAE

(RAIR) mediated by theautonomic nervous

system

Stool in contact with

sensitive receptors in

anal canal

Sigmoid

contraction

Defecation

convenient

Defecation

inconvenient

Puborectalismuscle

contraction

EAEcontraction

Accommodationof rectum to its

contents

Mediated by thevoluntary

nervous system

Diaphragms andabdominal

musclecontraction

Increasedintrarectalpressure

Puborectalismuscle relaxation

EAS relaxation

Mediataed bythe voluntary

nervous system

Defecation

postponed

Evacuation

of stools

Simultaneous

contraction of EAE

giving time to

decide if

circumstances are

are appropriate for

defecation


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Painful defecation

Fear of

defecation

A faecal mass

accumulates in

rectum

With-holding

behaviour

Functional megarectum

Loss of rectal sensitivity

Pelvic floor muscle fatigue

Anal sphincter incontinence

Overflow incontinence


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Healthy infants ; < 6 months

Childs learning process

Significant discomfort and excessive strainingassociated with passing soft stools

Resolve spontaneously few weeks Related to a failure to coordinate increased intra-

abdominal pressure with pelvic floor relaxation

No intervention rectal stimulation should be

avoided to prevent artificial sensory experiences Unnecessary laxatives


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Intestinal neural displasia

Visceral myopathies

Visceral neurophaties

Confirm Diagnosis with studies of colonic function :

Radio-opaque marker studies

Scintigraphy

Colonic manometry


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Schappi MG, et al. Gut. 2003 ; 52(5) : 275-5


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The incidence : 1 in 5,000 live births The most cause of lower intestinal

obstruction in newborn

3% of children and toddler with severe

refractory constipation

A congenital condition characterized by

the absence of ganglion cells in the

submucosal (Meissners) and myenteric

(Auerbachs) plexus of the distal small

bowel The length of intestine involved varies

Functional obstruction results


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Should be suspected in:

- any infant who doesnt pass

meconium within the first

24 hours of life

- newborn intestinal obstruction

- constipation / chronic

abdominal distentionin the first year of life


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History and physical examination

Perianal area, spine, reflexes, distal

extremities, digital rectal examination Constipation early of life : serious

congenital disorder

Constipation first year of life : 40%functional constipation


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Occult blood in stool associated abdominalpain, failure to thrive, and intermittentdiarrhea

Positive occult blood test : enterocolitis,intestinal inflammation.

Others lab : hypercalcemia, hypothyroidismand coeliac disease

Sweat test : delayed meconium suspectedcystic fibrosis


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Not indicated inuncomplicatedconstipation

Abdominalradiograph :detection of faecalimpaction (obese

child)


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The absence of

gangglion cells


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Rectal biopsy


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Functionalconstipation

Hirschcprungsdisease

Starts at birth no yes

Fecal incontinence often rare

Rectal fecal mass yes no

Retentive posturing yes no

Passage of large stool often rare

Anal fissures common rare


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Child & family education

Treat fecal impaction

Maintenance trerapy ( stoolsofteners preferred to stimulantlaxatives)

Toilet training advise


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Explanation normal defecation mechanism Pathogenesis of functional constipation

Toilet training

Positive and supportive attitude of parents

Explanation chronicity and possiblerecurrences


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Oral :> 2 years :- polyethylene glycol- mineral oil

- Lactulose or sorbitol Rectal :

- Glycerine supp- Physiological enema_ Contraindicated : soap supp, tap water, or

magnesium enema


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Diet :- increased intake of fluid

- reduce dairy products

- natural fibre ingestion

Behavioural modification :

- Regular toilet habits

- Unhurried time after meals

- Diaries of stool frequency

- Reward system

Medication :- Continuous for 3-6 months

- Lubricants and osmotic agents


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Follow-up 1-2 weeks ; 1 month and every 3, 6 months

Toilet training evaluation

Gradual weaning of medication after months

Maintenance treatment in 6 24 months

30% of children followed beyond puberty continue to haveconstipation and/or fecal incontinence

Adult study (n=63) : 22 patients had megarectum. Almost allhad fecal incontinence and 90% were on laxative sincechildhood

30% persistent constipation in adolescent (constipation andsoiling)

Relapse in 4 years


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Functional constipation is common Children with chronic intractable constipation

who do not improve with standard medicaltherapy may need anal sphincter & colon

function evaluation Colon motility studies help in surgical

decision making & help predict the outcomeof cecostomy

Anorectal and colon manometry also helps inevaluating defecation problem followingHirschsprungs surgery


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constipation smt vi 2010

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