PCH/PCCN Functional Constipation Pathwaypccnprovider.org/wp-content/uploads/2019/05/CP_Constipation_7.11.18...PCCN PCP Pathway for Diagnosis and Management of Functional Constipation

PCH/PCCN Functional Constipation Pathway

PCCN PCP Pathway for Diagnosis and Management of Functional Constipation in ChildrenPathway Key

Exclusion Criteria• History of/Concern for: – Hirschsprung’s Disease – Cystic Fibrosis –InflammatoryBowelDisease –Hypothyroidism –Spinaldysraphism –Neurogenicbowel/bladder•GIdysmotilitydisorderdiagnosedbyapediatricgastroenterologist

•J-tubeorcecostomytube• Presence of one or more of the following alarm signs and symptoms: –Constipationstartingwithinthefirst

monthoflife –Passageofmeconium>48hours oflife –Brightredbloodinstoolintheabsence

ofanalfissureorlarge,rockhardstools –Failuretothrive –Fever>orequal38.4degreesCelsius –Biliousvomiting –Severeabdominaldistension –Perianalfistula –Abnormalpositionofanus (e.g.anteriorlydisplaced) –Fearoutofproportionthanexpected

withanalinspection(i.e.concernforprevioussexualabuse)

•Hemodynamicinstability•Peritonealsignspresent•Bowelobstructionsuspected•Concernforacuteabdomen•Suspectedtoxicmegacolon•Persistentvomitingwitheitherhighfever,dehydrationthatisnon-responsivetoERtreatment,severeelectrolyteabnormalitiesoracuterenalfailure

•Abdominalmasswithacuteperitonealorobstructivesigns

•Abdominalabnormalitieswithabsentbowelsoundsandconcernforcompleteileus

•SevereabdominalpainpersistentlyrequiringtreatmentwithIVanalgesicsatleastevery2to4hours

•ActiveupperorlowerGIbleeding

Common Constipation Signs/Symptoms•Excessivestoolretention•Painfulorhardbowelmovements•Largediameterstoolsthatmayobstructthetoilet

•Retentiveposturingorexcessivevolitionalstoolretention

Symptoms that disappear immediately following passage of a large stool, including, but not limited to:•Irritability•Abdominalpain•Abdominaldistension• Decreased appetite•Earlysatiety

Indications for Abdominal Imaging•Ingeneral,theuseofabdominalimaginginthediagnosisofconstipation is not supported by theliterature

•Abdominalimagingmaybeconsideredincaseswherethediagnosisofconstipationissuspected,butnotsupportedbyhistoryand/orphysicalexamination

Warning SignsReturn to PCP:•Abdominaldistension•Vomiting•Inabilitytotolerateoralintake•FeverEvidence for return of constipation and indication to perform another clean out as evidenced by:•Nostoolin>48hours•Recurrenceoffecalsoiling•PassageofhardstoolsGo to ER/Urgent Care:•Biliousvomiting•Severeabdominalpain• Dehydration

•Hemodynamicinstability•Peritonealsignspresent•Bowelobstructionsuspected•Concernforacuteabdomen•Suspectedtoxicmegacolon•Persistentvomitingwitheitherhighfever,dehydrationthatisnon-responsivetoERtreatment,severeelectrolyteabnormalitiesoracuterenalfailure

Emergency Room Evaluation Required for:•Abdominalmasswithacuteperitonealorobstructivesigns

•Abdominalabnormalitieswithabsentbowelsoundsandconcernforcompleteileus

•SevereabdominalpainpersistentlyrequiringtreatmentwithIVanalgesicsatleastevery2to4hours

•ActiveupperorlowerGIbleeding

Created in partnership withGastroenterologyatPhoenixChildren’sHospital

Contraindication to NG tube•FacialFracture•Basilarskullfracture•Esophagealstricture•Esophagealvaricies•Bleedingdisorders•WorkingGTthatmaybeused forGolytelycleanout(jumpto Golytelycleanoutandprovide viaGT

©2018PhoenixChildren’sHospital,Inc.Allrightsreserved.Thismaterialisintendedonlyasaneducationalresourceandnotmeanttosubstituteindependentmedicaltraining,experienceorjudgment.1

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YES

Primary Care Provider Functional Constipation Pathway


Concern for constipationand/or fecal impaction

See common constipationsigns/symptoms

Does patienthave any exclusioncriteria or need for

ER evaluation?

Discontinuepathwayand continue

appropriateworkupYES

NO

Perform rectal stimulation and/or “bicycle kicks“YESIs the patient

< 6 months of age?Pt. stools and is

clinically improved?

YES

Dischargehomewithpearorprunejuice(1-2ouncesperday)prntokeepstoolingsoftandpainless.Goalisforformula fed infants tostoolevery1to3dayswithimprovementinsymptomsandbreastfed infantstostoolevery1to5dayswithoutsymptoms.Returntoclinicifworseningsymptomsorlackofstoolingintimeframesnotedabove.MaygiveappropriatelysizedglyecerinsuppositoryPRx1tohelpinitiatestooling.Glyecerinsuppositoriesshouldnot be used as a chronic maintenancetherapy.

In the last 1 - 2 weeks has patient

had less than 2 stools ORstool soiling (if potty trained) OR

stools that clog the toilet (if potty trained) OR

painful, hard stools that are hard to pass?

NO

Ifnostoolin1to2daysand/orclinicallyworseningdiscontinuepathway

See indications for abdominal imagine

Workup leads back to diagnosis

of functional constipation


appropriateworkup


appropriateworkup

NO

Go topage 3

YES

NO

1

2

4

continued on next page…

START HERE

NO


appropriateworkup

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Primary Care Provider Functional Constipation Pathway


Discharge with home clean out followed by maintenance therapy instructions

Continued from page 2

3

6-12mos 12-24mos 2-5years ≥5years

Rx 0.5 capful (8.5 g) Miralax mixed in 4

ounces of Pedialyte once daily until infant stools every 1 to 5 days with

improvement in symptoms

Rx 1 capful (17 g)Miralax mixed in 8 ozof clear liquids once

per day

For 3 days:Rx 1 capful (17 g)

Miralax mixed in 8 ozof any liquid three

times a day.

For 3 days:Rx 1 capful (17 g)

Miralax mixed in 8 ozof any liquid four

times a day.CLEANOUT

MAINTENANCE Wean/Use Miralax

as toleratedEnsure infant is

always well hydrated

Wean/Use Miralaxas tolerated

Promote good hydration and a diet rich in fiber

and fresh fruit

Rx 1 capful (17g) Miralax mixed in 8 oz of clear liquids

once to twice a dayPromote good hydration

and a diet rich in fiber and fresh fruit

Rx 1 capful (17g) Miralax mixed in 8 oz of clear liquids

once to twice a dayPromote good hydration

and a diet rich in fiber and fresh fruit

Schedule patient follow-up in 2 weeks

At follow-up:•Assesssymptoms•Askaboutadherencetoregimen•Provide(re)educationasneeded•Rampbackuptocleanoutorweanoffmedsasapprorpriate

•Considerbehavioralhealthconsultation•Treatanyrecurringfecalimpaction

Treatmenteffective?

RefertopedsGI

NO

YES

Educate on warning signs that warrant return to immediate medical attention

Continue maintenancetherapy as above Relapse? NO

Wean/Observe/

Reassess as needed

YES

ER/UC Functional Constipation Pathway


Concern for constipation and/or

fecal impaction 2

Doespatient haveany exclusion

criteria?

1

Is the patient < 6 months of

age?

NO

NO

In the last 1 - 2 weeks has patient

had less than 2 stools ORstool soiling (if potty trained) OR

stools that clog the toilet (if potty trained) OR

painful, hard stools that are hard to pass?

YES

Go topage 5

YESDiscontinuepathway

and continue appropriateworkup

YESTry rectal

stimulation and/or “bicycle kicks”

Patient stools and is


Dischargehomewithpearorprunejuice(1-2ouncesperday)

YES

NO

Give glycerin suppository



YES

Discontinue pathwayand

continue appropriate workup

NO


appropriateworkup(seeindicationsforabdominalimaging)

NO

4

Go topage 5 continued on

next page…

ER/UC Functional Constipation Pathway




Workup leads back to

diagnosis of functional constipation?

Continuedfrom page 4

Does the patient have a hard

mass in the lower abdomen OR a dilated rectum filled

with a large amount of stool on rectal

exam?

To soften stool in rectum, give mineral oil enema and wait 30 minutes.Dosing:1 - 2 years of age = 6 cc/kg PR x 12 - 11 years of age = 30 - 60 cc PR x 1> 11 years of age = 120 cc PR x 1


NO YES

To stimulate stooling, give Fleet enema and wait 30 minutes.Dosing: 2.5 cc/kg PR x 1 (max 133 cc) and wait 30 minutes





NO

YES

Discharge with home clean out (if > 2 years old) followed

by maintenance therapyinstructions and plan to

follow up with PCP in 1 to 2 days. Educate on warning signs that warrant return to

immediate medical attention.

3

NO

6-12mos 12-24mos 2-5years 5-10years ≥10years

Prescribe 0.5 capful (8.5 g)Miralax mixed in 4 ounces

of Pedialyte once daily until infant stools every 1 to 5 days with improvement in

symptoms

Prescribe 1 capful (17 g)Miralax mixed in

8 ounces of clear liquidsonce per day

For 3 days:Prescribe 1 capful (17

grams) Miralax mixed in 8 ounces of any liquid

three times a day.



four times a day.CLEANOUT

MAINTENANCE

Wean/Use Miralaxas tolerated

Prescribe 1 capful (17g) Miralax mixed in

8 ounces of clear liquids once to twice a day

YES



four times a day.

Wean/Use Miralax as tolerated


8 ounces of clear liquids once to twice a day


8 ounces of clear liquidstwice a day

Go topage 7

Hospital Functional Constipation Pathway


Is the patient ≥

12 months of age?

Patient hospitalized with funtional constipation

and in need of clean out

YES

Doespatient haveany exclusion

criteria?

1

Haspatient failed aenteral/rectal

clean out?

NO

Doespatient have anycontraindication

to NG tube?

YES

5

Go topage 7

YESDiscontinuepathwayand consider other

appropriatenextsteps

Discontinue pathwayNO

NO

YES

NO

12-24mos 2-5years ≥5years

Prescribe 1 capful(17 grams) Miralax mixed in 8 ounces of any liquid

two times a day


three times a day.


four times a day.

Inpatient Oral Clean Out

Patientstools, is able to

tolerate enteral intake and is clinically

improved?

YES

YES continued on next page…

Hospital Functional Constipation Pathway




NONO

Does the patient have a

J-tube or a cecostomy?

NO

YES

Place NGT and follow PCH NGT protocol

Not ready for use

Start NGT Golytely CleanoutStartwithdoseof5-10cc/kg/hourandrampuptoagoalrateof20cc/kg/hour(max500cc/hour).Ifnottolerated,stop30minutesandthenresumemostrecenttolerateddosethanrampupslower(10-15cc/houreveryotherhourastoleratedtomaxdose).Placeptonclearliquiddiet(avoidredliquids).Ifpatientunabletotakeinaclearliquiddiet,runPedialyteinNGTfor2hoursq12hours(totalvolumePedialyte=hourlymaintenanceratex12hours)insteadofGolytely.IfpatientunabletotolerateclearliquiddietorNGTPedilatye,runMIVFinstead.Followcloselyforadequatehydration.BMPnotroutinelyrequiredonadailybasis.IfGolytelygoingformorethan48hoursconsiderBMP.

ContinueGolytelyInfusion

Patient’s stools are no longer brown AND there

is minimal stool or sediment present AND patient is able to tolerate

enteral intake AND isclinically improved?

NO

12-24mos 2-10years ≥10years

Prescribe 1capful (17g)

Miralax mixed in 8 ounces ofclear liquidsonce per day

Continue clean out regimen for a total of 3 days

(includehospitaldaysincount)

YES

Attendingprovider able to

update PCP and arrange follow up appt within

1 to 2 weeks?

Follow up apptplaced in discharge

instructions

YES

NOExplore otherappropriate

follow up options

Discharge with home clean out (if > 2 years

old) followed bymaintenance therapyinstructions and plan to follow up with PCP

in 1 to 2 weeks. Educate on warning signs that warrant

return to immediate medical attention

3

Prescribe 1capful (17 g)

Miralax mixed in 8 ounces ofclear liquidstwice a day

Prescribe 1capful (17g)

Miralax mixed in 8 ounces ofclear liquids

once to twice a day

MAINTENANCE

YES

Discontinuepathwayand consider other

appropriatenextsteps

©2018PhoenixChildren’sHospital,Inc.Allrightsreserved.Thismaterialisintendedonlyasaneducationalresourceandnotmeanttosubstituteindependentmedicaltraining,experienceorjudgment.

PCH/PCCN Funtional Constipation Pathway

ScopeThisguidelineisaimedatimprovingthediagnosisandmanagementofchildrenwithfunctionalconstipationintheappropriatecaresetting;decreasingtheuseofunnecessaryimagingstudiesfortheevaluationandmanagementoffunctionalconstipation;decreasingtheuseofin-hospitalGolytelycleanoutsvianasogastrictubeforthemanagementoffunctionalconstipation;andempoweringcommunitypediatricianstodiagnoseandmanagefunctionalconstipationintheofficesetting.

Definitions• PCH=PhoenixChildren’sHospital• PCCN=PhoenixChildren’sCareNetwork• Functional Constipation=chronicidiopathicconstipationthatdoesnothaveananatomicorphysiologicalcause

• PHIS Database=PediatricHealthInformationSystems(PHIS)databaseisacomparativepediatricdatabasethatincludesclinicalandresourceutilizationdataforinpatient,ambulatorysurgery,emergencydepartmentandobservationunitpatientencountersformorethan45children’shospitals.ThisdatabaseisownedandoperatedbytheChildren’sHospitalAssociation.

BackgroundFunctionalconstipationisacommonprobleminchildhood,withanestimatedprevalenceof3to5percentinchildrenaged4-17yearsandisresponsiblefor35%ofallvisitstopediatricgastroenterologists.(Hyman,Milla,Benninga,etal,2006)(Rasquin,DiLorenzo,Forbes,etal,2006)Despitethehighresourceutilizationofpediatricconstipation,therearecurrentlystillnoclear,well-knownguidelinesforthemanagementandtreatmentofpatientswithfunctionalconstipation.

Constipationmostcommonlyoccursin3pediatricgroups:infantsweaningfrombreastmilkorformula,toddlerstoilettraining,andschool-agedchildren.AccordingtoaconsensusopinionoftheEuropeanSocietyforPaediatricGastroenterology,HepatologyandNutrition(ESPGHAN)andtheNorthAmericanSocietyforPediatricGastroenterology,HepatologyandNutrition(NASPGHAN),functionalconstipationisdefinedbyfulfillingamodifiedversionoftheRomeIIIcriteriaforconstipationasnotedbelow.(Hyman,Milla,Benninga,etal,2006)(Rasquin,DiLorenzo,Forbes,etal,2006)

Furthermore,theterm“functionalconstipation”isdefinedbyconstipationthatdoesnothaveaphysiologicalorphysicalcause.Constipationaffectsabout30%ofchildrenand,ofthiscohort,95%ofcasesarefunctionalinnature.

Expertopinionpromotesaggressiveoutpatientmanagementoffunctionalconstipationwithpolyethyleneglycol(PEG),sorbitol,andlactulose.Also,pediatricenemasareoftenusedtotreatfecalimpaction.(Rasquin,DiLorenzo,Forbes,etal,2006)Invasivemanagementwithhospitalization,placementofanasogastrictubeandadministrationofcontinuousGolytelyshouldbe

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Disclaimer:Thisguidelineisnotintendedtoreplaceclinicaljudgment.Itismeanttoassistlicensedindependentpractitionersandotherhealthcareprovidersinclinicaldecisionmakingbydescribingarangeofgenerallyacceptableapproachestothediagnosisandmanagementofaparticularcondition.Aparticularpatient’scircumstancesshouldalwaysbetakenintoaccountwhena practitioner is deciding on a courseofmanagement.

Rome III Diagnostic Criteria for Functional ConstipationIntheabsenceoforganicpathology,greaterthanorequalto2ofthefollowingmustoccur:• For a child with a developmental age less

than or equal to 4 years* –Lessthanorequalto2defecations perweek –Atleast1episodeofincontinenceperweek aftertheacquisitionoftoiletingskills

–Historyofexcessivestoolretentionor painfulorhardbowelmovements

–Presenceofalargefecalmassintherectum –Historyofalarge-diameterstoolsthatmay obstructthetoilet

–Accompanyingsymptomsmayinclude irritability,decreasedappetite,and/orearly satiety,whichmaydisappearimmediately followingpassageofalargestool

• For a child with a developmental age greater than or equal to 4 years with insufficient criteria for IBS+

–Lessthanorequalto2defecationsinthe toiletperweek

–Atleast1episodeoffecalincontinence perweek –Historyofretentiveposturingorexcessive volitionalstoolretention

–Historyofpainfulorhardbowelmovements –Presenceoflargefecalmassintherectum –Historyoflargediameterstoolsthatmay obstructthetoilet

*Criteria fulfilled for at least 1 month. (Hyman, Milla, Benninga, & al, 2006)

+Criteria fulfilled at least once per week for at least 2 months before diagnosis. (Rasquin, Di Lorenzo, Forbes, et al, 2006)

reservedfortherareinstancewhenaggressiveoutpatientmanagementhasfailedandapediatricgastroenterologistbelievesthistreatmentisanecessarylastresort.

Ingeneral,radiationexposuresecondarytoimaginghasincreasedovertimeinthemedicalcommunity.Thispathwaywillpromotelimitingroutineabdominalx-rayforthediagnosisoffunctionalconstipation.ItwillalsopromoteadecreaseintheuseofNGTstomanagefunctionalconstipationwhichmay,decreasetherateofunnecessaryabdominalimaging.

Finally,weproposethatfunctionalconstipation,ideally,bemanagedonanoutpatientbasisbyprimarycareproviders(PCPs)inclosecollaborationwithgastroenterology.ThisguidelinethereforealsoaimstolowercostbyavoidingunnecessaryhospitalizationswhileencouragingandempoweringPCPstodiagnoseandtreatfunctionalconstipationonanoutpatientbasisbyprovidingtoolsspecificallydesignedfortheoutpatientmanagementoffunctionalconstipation.

Thechampionsofthisguidelinebeganworkingonthisguidelinein2015.Throughtheexercisesofdatareview,literaturereview,pathwaycreationandpromotionofthetopic,thechampionsofthisguidelinehavealreadybeguntoseedesiredeffects.Fordesiredtrendstocontinue,thechampionsofthisguidelinebelieveitnecessarytoformallyputintopracticethesepathwaysandguidelines.

Inclusion Criteria (See Appendix 1)

•Childrenage0to18yearsofage(uptoandincludingtheentire18thyear)

•Historyof>orequaloneofthefollowing: –Excessivestoolretention –Painfulorhardbowelmovements –Largediameterstoolsthatmayobstructthe

toilet

–Retentiveposturingorexcessivevolitionalstoolretention

–Symptomsthatdisappearimmediatelyfollowingpassageofalargestool,including,butnotlimitedto:

oIrritability oAbdominalpain oAbdominaldistension o Decreased appetite oEarlysatiety – Inthelast1-2weeks: oLessthan2stools oStoolsoiling(ifpottytrained) oStoolsthatclogtoilet oPainfulhardstoolsthatarehardtopass –Hardmassinthelowerabdomenbelievedto befecalmaterial

–Dilatedrectumfilledwithalargeamountof stoolonrectalexam

•Forpurposesofdatacollectionusingclaimsdata,patientswillbeincludedifaclaimpossessesoneoftheICD-10codesoutlinedinAppendix2meanttorepresentfunctionalconstipationaslongasthatdiagnosisappearsanywhereinposition1-5ontheclaim.

Exclusion Criteria (See Appendix 1)

•Historyofand/orConcernfor: – Hirschsprung’s Disease – Cystic Fibrosis – InflammatoryBowelDisease –Hypothyroidism –Spinaldysraphism –Neurogenicbowel/bladder –GIdysmotilitydisorderdiagnosedbya

pediatricgastroenterologist•Presenceofoneormoreofthefollowingalarmsignsandsymptoms:

–Constipationstartingwithinthefirstmonthoflife

–Passageofmeconium>48hoursoflife



–Brightredbloodinstoolintheabsenceofanalfissureorlarge,rockhardstools

–Failuretothrive –Fever>orequal38.4degreesCelsius –Biliousvomiting –Severeabdominaldistension –Perianalfistula –Abnormalpositionofanus(e.g.anteriorly

displaced) –Fearoutofproportionthanexpectedwithanal

inspection(i.e.concernforprevioussexualabuse)

–Hemodynamicinstability –Signsofperitonitis –Bowelobstructionsuspected –Concernforacuteabdomen –Suspectedtoxicmegacolon –Persistentvomitingwitheitherhighfever,

dehydrationthatisnon-responsivetooutpatienttreatment,severeelectrolyteabnormalitiesoracuterenalfailure

–Abdominalmasswithacuteperitonealorobstructivesigns

–Abdominalabnormalitieswithabsentbowelsoundsandconcernforcompleteileus

–SevereabdominalpainpersistentlyrequiringtreatmentwithIVanalgesicsatleastevery2to4hours

–ActiveupperorlowerGIbleeding•Forpurposesofdatacollectionusingclaimsdata,patientswillbeexcludedifaclaimpossessesanyoneoftheICD-10codesoutlinedinAppendix1inanypositionontheclaim.

•AnypatientpresentingforGIcleanouttothePCHERorhospitalwithaJTand/orcecostomywillbeexcludedfromthispathway

Pathway Goals•Managefunctionalconstipationintheappropriatecaresetting(i.e.whenappropriate,utilizethePCPofficeortheGastroenterologyofficeratherthantheEDorhospital)

•Decreasetheuseofunnecessaryimagingstudiesfortheevaluationandmanagementoffunctionalconstipation

•Reservetheuseofin-hospitalNGGolytelycleanoutsforthemanagementoffunctionalconstipationforthosepatientswhohavebeennon-responsivetoprevious,appropriateinterventions

•EmpowercommunityPCPstofeelpreparedtodiagnoseandmanagefunctionalconstipationintheofficesetting

Key Clinical Recommendations1.Evidencedoesnotsupporttheuseofdigitalrectalexaminationtodiagnosefunctionalconstipation.

2.Evidencedoesnotsupporttheuseofabdominalradiographyorcolonictransitstudiestodiagnosefunctionalconstipation.

3.Educatepatientsandfamiliesontheimportanceofhydrationandadietrichinfiberandfreshfruits;howeverifsymptomspersist,evidencedoesnotsupporttheuseoffibersupplements,extrafluidintakeorpre/probioticsastheonlytreatmentsofferedforfunctionalconstipation.

4.Polyethyleneglycol(PEG)andenemasareequallyeffectiveforfecaldis-impaction.

5.PEGisamoreeffectivetreatmentforfunctionalconstipationwhencomparedwithlactulose,milkofmagnesia,mineraloilorplacebo;howeverlactuloseisconsideredsafeforallagesandisthereforerecommendedifPEGisunavailable.

6.In-hospitalcleanoutswithPEGviaNGTshouldbetheexception,nottherulefortreatingfunctionalconstipation

7.UponcompletionofahospitalcleanoutwithPEGviaNGTitisnotnecessarytoobtainanabdominalradiographtodemonstratecompletion.Instead,cleanoutshouldbeconsideredcompleteoncepatientispassingliquidstoolwithoutdifficulty,patientisfreeofabdominalpainandpatientisabletotolerateoralintake.

Development/Approval/Implementation Process1.GuidelineChampions:SamFlores,MD;JodiCarter,MD;GarySilber,MD;MitchShub,MD;ZebTimmons,MD;KellyKelleher,MD;JamieLibrizzi,MD;KeithMorse,MD

2.ApprovedbyPCHClinicalPathwaysCommittee:6/6/17

3.ApprovedbyClinicalEffectivenessCommittee:8/17/17

4.ApprovedbyPCCNQualityCommittee:9/13/175.ApprovedbyPCCNBoardofManagers:10/11/17

6.OfficialLaunchDate:January29,20187.UpdatedLiteratureReviewandRevisionsdue:oneyearfrompathwayapprovaldate=June 2018

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Works Cited


Boccia,G.,Manguso,F.,Coccorullo,P.,&al,e.(2007).FunctionalDefecationDisordersinChildren:PACCTCriteriavs.RomeIICriteria.Journal of Pediatrics,151,394-8.

Hyman,P.,Milla,P.,Benninga,M.,&al,e.(2006).ChildhoodFunctionalGastrointestinalDisorders:Neonate/Toddler.Gastroenterology, 130,1519-26.

Rasquin,A.,DiLorenzo,C.,Forbes,D.,&al,e.(2006).ChildhoodFunctionalGastrointestinalDisorders:Child/Adolescent.Gastroenterology, 130, 1527-37.

Tabbers,M.,C,D.L.,MY,B.,C,F.,MW,L.,&Nurko,e.a.(2014).EvaluationandTreatmentofFunctionalConstipationinInfantsandChildren:Evidence-BasedRecommendationsfromESPGHANandNASPGHAN.Journal of Pediatric Gastroenterology,58,258-274.

Appendix I


INCLUSION CRITERIA

Q42015-Q42016 ICD-10 CM CODES

Constipation,unspecified K59.00

Other constipation K59.09

Outletdysfunctionconstipation K59.02

Slowtransitconstipation K59.01

Overflowincontinence N39.490

Incontinenceoffeces R15.9

Fecalimpaction K56.41

EXCLUSION CRITERIA

DIAGNOSIS/PROCEDURES ICD-10 CM CODES ICD-10 PCS CODES CPT CODES HCPCS CODES

Hirschsprung’s Disease Q43.1

Cystic Fibrosis E84.0-E84.9

Crohns Disease K50.00-K5.919

UlcerativeColitis K51.00-K51.919

Hypothyroidism E03.0-E03.9

SpinaBifida Q05.0-Q05.9

TetheredCord Q06.8-Q06.9

NeurogenicBowel K59.2

NeurogenicBladder N31.0-N31.9

GIDysmotility K59.8-K59.9

SpinalCordTumor C72.0,C72.1,D33.4

Colonoscopy0DJD8ZZ

45378-45398 G0105,G0120,G0121

Sigmoidoscopy 45330-45350 G0104,G0106

JejunostomyTubePresent Z93.4

CecostomyTubePresent Z93.3

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PCH/PCCN Functional Constipation Pathwaypccnprovider.org/wp-content/uploads/2019/05/CP_Constipation_7.11.18...PCCN PCP Pathway for Diagnosis and Management of Functional Constipation