Constipation

last authored: Oct 2009, Dave LaPierre

 

Introduction

Constipation is a very common concern, the most frequent GI complaint in children. It is defined by less frequent stool, hardness, associated with symptoms.

 

The Case of...

return to top

 

 

Differential Diagnosis

The vast majority (over 95%) of pediatric constipation is functional, caused by psychological or dietary issues.

 

acronym: DUODENUM

Diet

  • low fibre
  • dehydration

ψsychiatry

  • depression
  • somatization
  • OCD

Obstruction

 

Drugs

  • iron
  • opioids
  • TCAs
  • neuroleptics
  • antihistamines
  • calcium channel blockers
  • antacids
  • methylphenidate
  • lead

Endocrine

  • diabetes
  • hypothyroidism
  • hypercalcemia
  • hypokalemia
  • hypomagnesemia
  • uremia

Neurologic

  • spinal cord injury
  • Parkinson's
  • multiple sclerosis
  • stroke
  • autonomic neuropathy
  • neural tube defect

Unknown

 

Miscellaneous

return to top

 

 

History and Physical Exam

  • history
  • physical exam

History

When did it start?

  • Hirschprung's: begins from birth; delayed passage of meconium

shape of stool

  • functional: large stools that can clog the toilet

 

children behaviours

  • parental coercion
  • 'the busy' child
  • diet
  • availability of toilet
  • "the poopdance" or other maneuvers as kids try to retain stool

soiling

  • encopresis: with functional constipation

Physical Exam

Height and weight

HEENT

  • thyroid

abdominal

  • can often find fecalomas
  • rectal exams not necessary if a classical history of functional. Consent is incredibly important. Anal reflex -

lowe back for occult neural tube defect

return to top

 

 

Investigations

  • lab investigations
  • diagnostic imaging

Lab Investigations

If treatment of functional constipation does not work, investigations should be done for

  • celiac
  • TSH
  • electrolytes

Blood tests - CBCD, electrolytes, Ca, Mg, urea, creatinine, glucose, TSH

Diagnostic Imaging

An abdominal X-ray can show obstruction etc. On flat X-ray, divide abdomen into 4 quadrants, and rate the amount of stool in each from 0-3. Constipation is suggested if score is >6/12.

return to top

 

 

Management

For functional constipation, education of patients and families is first. Disimpaction is the next step: PEG is the first line, and should be kept up for a few weeks or months. It is not addictive and can be stopped abruptly with no concerns.

 

Diet is key in preventing constipation. Wheat bran, high-bran cereals, psylium 2-3tsp/d can all provide insoluble fibre. Exercise and adequate hydration are also very important.

 

Behaviour modification: setting reasonable expectations, routine (5 min after breakfast and supper), rewards.

 

Laxatives, in order of increasing potency, include:

Manual disimpaction can be used in people for whom stool has hardened to such a degree it can not be expelled.

Medications that cause constipation should be reduced or held as soon as is possible.

 

return to top

 

 

Pathophysiology

Fecal withholding in children

 

Children can become quite afraid of defecation for a number of reasons, including parental pressure, painful bowel movements, or fear of toilets. Accordingly, fecal withholding is quite common as a cause of defecation.

 

return to top

 

 

The Case of...

 

return to top

 

 

Additional Resources

 

 

return to top

 

 

Topic Development

created: DLP, Aug 09

authors: DLP, Aug 09

editors:

reviewers:

 

 

return to top