CONSTIPATION)IN)CHILDREN constipation)in)children dr.)hossain)ibrahimageel)) pediatric)gastroenterologist))

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Text of CONSTIPATION)IN)CHILDREN constipation)in)children dr.)hossain)ibrahimageel))...

  •  CONSTIPATION  IN  CHILDREN

    DR.  HOSSAIN  IBRAHIM  AGEEL     PEDIATRIC  GASTROENTEROLOGIST    

    PEDIATRIC  DEPARTMENT      KFCH  –  JAZAN    

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  • PREVALENCE     •  Common  problem  in  childhood.     •  The  worldwide  prevalence  rates  1%  -­‐  30%.     •  3  to  5  percent  of  all  visits  to  pediatricians.     •  25  percent  of  pediatric  GI  consults.  

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  • Defini=on       •  Infrequent  bowel  movements.     •  Hard  stool  consistency.     •  Large  stool  size.                                          Painful  defecaHon

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  • “NASPGHAN”  defini=on a  delay  or  difficulty  in  defecaHon,  present   for  two  weeks  or  more,  and  sufficient  to   cause  significant  distress  to  the  paHent.      

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  • q   Normal  stool  frequency           •  The  iniHal  bowel  movement  is  within  the  first  24  hours   of  birth  in  90  percent  of  normal  newborns.      

    •   Approximately  4  stools  per  day  in  the  1st  week  of  life  .     •  Gradually  changes  to  1-­‐2  stools  per  day  by  the  age  of  4   years  with  range  of  3  per  day  to  3  per  week.    

    •   BreasRed  infants  can  stool  with  each  feeding  or  only   once  every  7  to  10  days.    

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  • q   Bowel  control     •  Many  children  achieve  voluntary  bowel  control   between18  months  and  2  years  of  age.    

    •  Majority  of  children  (98%)  are  toilet  trained  by   4  years  of  age.    

    •  Girls  achieve  toilet  training  slightly  earlier  than   boys.

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  • ANATOMY  OF  ANORECTAL  REGION

    l  Major structures include: ¡ External anal sphincter ¡ Puborectalis muscle ¡  Internal anal sphincter ¡ Rectum

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  • NORMAL  DEFECATION  MECHANICS

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  • E=ology  of  cons=pa=on

    q     Func=onal  cons=pa=on:     – ConsHpaHon  without  objecHve  evidence  of  a   pathological  condiHon.    

    – Accounts    for  >  95%  of  all  consHpated  children.       q     Organic  causes:    

    – Disease  enHHes.     – Accounts  for  less  than  5%  of  all  consHpaHon.  

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  •                        ORGANIC  CAUSES  OF  CONSTIPATION Imperforated  anus     Anal  stenosis   Anteriorly  displaced  anus  

    Anatomic  malformaHon

    Hypothyroidism     Hypokalemia     Hypercalcemia   Celiac  disease     CysHc  fibrosis  

    Metabolic  causes

    Cerebral  palsy     Spina  bifida     Tethered  cord     Spinal  cord  trauma/tumor   Neurofibromatosis  

    Neuropathic  condiHons

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  •                        ORGANIC  CAUSES  OF  CONSTIPATION Hirschsprung  disease     IntesHnal  Neuronal  Dysplasia     IntesHnal  pseudo-­‐obstrucHon   Gastroschisis  

    IntesHnal  nerve  or   muscle  disorders

    Opiates     Phenobarbital     AnH-­‐cholinergics     AnH-­‐depressants     ChemotherapeuHc  agents     Sucralfate     Antacids     Lead  toxicity  

    Drugs/Toxins  induced

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  • Painful  stool   Voluntary   withholding   of  feces  

    Prolonged  fecal   stasis  with  fluids  

    resorp=on  

    Larger  and   harder  stool  

    Rectal   dila=on  

     Urge  to  defecate                      disappears

    PATHOGENESIS  OF  FUNCTIONAL  CONSTIPATION

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  •   Causes  of  painful  stools  :     •  Difficult  or  stressful  toilet   training.    

    •  Changes  in  rouHne  or  diet.     •  Stressful  events.     •  Illness  causing  dehydraHon.     •  Unavailability  of  toilets.     •  Withholding  while  busy  or   playing.    

    Func=onal  Cons=pa=on

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  • Func=onal  Cons=pa=on

    Withholding  behaviors  :   •  Squaeng.     •  Crossing  ankles.     •  SHffening  of  the  body.     •  Holding  onto  furniture   or  mother.    

    •  Flushing,  sweaHng  and   crying.    

    •  Hiding  during  defecaHon   in  a  corner.  

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  • l Functional constipation presents most commonly at three age periods:

    ¡  Introduction of cereals and solid foods. ¡ Toilet training. ¡ The start of school.

    Presenta=on    when?

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  • Diagnosis  of  func=onal  cons=pa=on

    ROME  III  criteria

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  • q   Infants  and  toddlers  less  than  4  years  of  age Must  include  1  months  of  at  least  two  of  the  followings:       •  Two  or  fewer  defecaHons  per  week.     •  At  least  one  episode  per  week  of  inconHnence  ager  the  

    acquisiHon  of  toilet  skills.     •  History  of  excessive  stool  retenHon.     •  History  of  painful  or  hard  bowel  movements.     •  Presence  of  a  large  fecal  mass  in  the  rectum.     •  History  of  large  diameter  stools  that  may  obstruct  the  toilet.    

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  • q   Older  children  or  adolescents  more  than  4  years  of  age

     Must  include  2  months  of  two  or  more  of  the  followings    occurring  at  least  once  per  week  :       •  Two  or  fewer  stools  in  the  toilet  per  week.     •  At  least  one  episode  of  fecal  inconHnence  per  week  .     •  History  of  retenHve  posturing  or  excessive  voliHonal  stool  

    retenHon.     •  History  of  painful  or  hard  bowel  movements.     •  Presence  of  a  large  fecal  mass  in  the  rectum.     •  History  of  large  diameter  stools  that  may  obstruct  the  toilet.    

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  • Associated  symptoms Toilet  habit Intes=nal  :     •  Abdominal  pain     •  Abdominal  disten=on     •  Vomi=ng     •   Anorexia       •   weight  loss  or  poor  wt  gain     Extra-­‐intes=nal     •  Urinary  tract  symptoms  such  

    as  frequency,  enuresis,  and   infec=on.      

    History  of  chief  complaint:     •  Age  of  onset  of  cons=pa=on       •  Stool  frequency     •  Stool  consistency     •  Stool  size     •  Painful  defeca=on     •  Blood  in  the  stool     •  Withholding  symptoms       •  History  of  encopresis       •  Time  of  1st  bowel  movement  

    CLINICAL  APPROACH  -­‐  HISTORY  

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  • Other  important  points  in  the  history  to  address Including  neonatal  GI  complica=ons   such  as  NEC  and  prior  surgeries  

    Past  medical  and   surgical  history

    Fluid  intake,  milk  consump=on,  fiber   content  of  food  stuffs

    Dietary  

    Cons=pa=on,  celiac  disease,  cys=c   fibrosis,  etc.

    Family

    Household  structure,  stressors,   temperament,  toilet  habits  at  school  

    Psychosocial  

    Toilet  training  history,  Development Developmental Laxa=ves  used  and  their  results,   drugs  known  to  cause  cons=pa=on