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Slide 1-

Constipation and Abdominal Pain Jennifer Maupin, RN, CPNP-PC Gastroenterology, Hepatology and Nutrition
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Guideline Resources, Constipation: Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014; 58:258-274.
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Guideline Resources, Abdominal Pain: Vandenplas Y, Rudolph CD et al. Pediatric gastroesophageal reflux clinical practice guidelines: Joint recommednations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49:498-547.
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Constipation
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Definition of Functional Constipation In the absence of organic pathology, 2 or more of the following symptoms in a child with a developmental age <4 years <2 defecations per week At least 1 episode of incontinence per week in a child that was previously potty trained History of excessive stool retention 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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Definition of Functional Constipation In a child with a developmental age >4 years and insufficient criteria for irritable bowel syndrome: <2 defecations in the toilet per week At least 1 episode of fecal incontinence per week History of retentive posturing or excessive volitional stool retention 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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Assessment History Onset of symptoms Stool consistency (Bristol Stool Scale) Stooling pattern, encopresis Blood in Stool (not unusual with passage of hard stool) Abdominal pain Appetite/weight Family history of GI problems including constipation
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Available on-line: www.gutsense.org (better than asking, “what does your poop look like?”)
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Red Flags Weight loss, poor linear growth Onset of symptoms in infants <1 month old (ask about passage of meconium at >48 hours of life) Blood with passage of soft stool Evacuation of explosive stools after withdrawal of the examining finger on digital rectal exam Text [Arial 22pt] Text [Arial 22pt]
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Differential Diagnosis Celiac disease Hypothyroidism, hypercalcemia, hypokalemia Diabetes mellitus Dietary protein allergy (milk) cholinergics, antidepressants, chemotherapy, heavy metal ingestion (lead) Vitamin D intoxication Botulism Cystic fibrosis Hirschsprung’s disease
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Differential Diagnosis Anal achalasia Colonic inertia Anatomic malformations (imperforate anus, anal stenosis) Pelvic mass (sacral teratoma) Spinal cord anomalies, trauma, tethered cord Abnormal abdominal musculature (prune belly, gastroschisis, Down syndrome) Pseudoobstruction (visceral neuropathies, myopathies, mesenchymopathies) Multiple endocrine neoplasia type 2B
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Red Flags Onset at <1 month of age Passage of meconium >48 hours of life Family history of Hirschsprung’s Disease Ribbon stools Blood in the stools in the absence of anal fissures or with passage of soft stools Failure to thrive (poor linear growth, poor weight gain)
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Red Flags Fever (infection? Inflammation?) Bilious vomiting (obstruction?) Abnormal thyroid gland (thyroid dysfunction?) Severe abdominal distention (obstruction?) Perianal fistula (IBD?) Abnormal position of anus
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Physical Exam Red Flags Absent anal or cremasteric reflex (anal reflex often absent in chronic constipation) Decreased lower extremity strength/tone/reflex (spina bifida?) Tuft of hair on spine (spina bifida?) Sacral dimple (spina bifida? tethered cord?) Gluteal cleft deviation Extreme fear during anal inspection (abuse?) Anal scars (surgical history? Abuse?)
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Diagnostic Testing Digital rectal exam: perform based on history X-ray (KUB): only needed if fecal impaction is suspected or physical exam (DRE) is not possible Colonic Transit Study (sitz marker test): only useful for evaluating for slow colonic transit Anorecal manometry: only useful in evaluation of HD and dyssynergia. If no RAIR (rectoanal inhibitory reflex), suction biopsy should be performed to evaluate for HD.
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Diagnostic Testing Colonic manometry: evaluates colonic dysmotility, recommend screening for colonic transit before performing manometry MRI of the spine: if tethered cord or other neurologic abnormalities suspected Colonic Scintigraphy: useful in measuring colonic motility in children with slow transit constipation.
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Diagnostic Testing Routine laboratory testing is not recommended If suspected, test for: Thyroid dysfunction: TSH, T-4 Metabolic dysfunction: Chem 10 Celiac disease: Celiac panel, IgA Food allergy: Immunocap Inflammatory markers: ESR, CRP Cystic Fibrosis: Sweat test
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Nonpharmacologic Treatment Current research does not support the use of: Fiber Hydration (fluid) Physical activity Prebiotics Probiotics Behavioral therapy
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Nonpharmacologic Treatment What is recommended: Normal fiber intake (age based)(fiber gummies are great!) Normal fluid intake (64 oz/day) Normal physical activity (1 hour/day) Patient education demystifying, explaining and providing guidance for toilet training
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Pharmacologic Treatment Polyethylene Glycol (Miralax) (OTC) Enemas (equally effective) (OTC) Less effective then Miralax: Lactulose (prescription only) Milk of magnesia (OTC) Mineral oil (OTC)
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Dosing Miralax Mix 1 capful (17 grams) with 8 oz of liquid DO NOT mix with milk or soda Consume within 15-20 minutes (not effective if placed in a sippy cup and consumed over 8 hrs) Titrate dose to achieve soft, but formed stool. Go as high as it takes. Text [Arial 28pt] Text [Arial 22pt] Text [Arial 22pt]
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Laxative Regimens Treatment of fecal impaction: Miralax 1-1.5 g/kg daily for 3-6 days Enema daily for 3-6 days Start daily laxative regimen after completed Miralax is preferred Use lactulose, milk of magnesia or mineral oil if Miralax is not available Combine therapies if a single therapy is not effective
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Expert Opinion Maintenance treatment should continue for at least 2 months. All symptoms of constipation should be resolved for at least 1 month before discontinuation of treatment. Treatment should be decreased gradually. In the developmental stage of toilet training, medication should only be stopped once toilet training is achieved.
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Novel Pharmacologic Therapies Medications that have been found to be effective in treating constipation in adults. Not currently recommended in children: Lubiprostone (Amitiza), chloride channel activator Linaclotide (Linzess), chronic idiopathic constipation tx Prucalopride (Resotran), serotonin 5-HT4 receptor agonist
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Surgical Treatment ACE (cecostomy) The antegrade delivery of cleansing solutions enables the patient to evacuate the colon at regular intervals, avoiding impaction of feces and reducing fecal incontinence.
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Other Treatment Options Transcutaneous Nerve Stimulation (TNS) TNS is a noninvasive and painless form of interferential therapy in which 4 surface electrodes are applied to the skin which produce 2 sinusoidal currents that cross within the body Evidence does not support the use of TNS in children with intractable constipation.
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Prognosis of Functional Constipation in Children Based on study of children referred to pediatric gastroenterologists: After 6-12 months: 50% will recover and be without laxatives 10% are well while taking laxatives 40% will still be symptomatic despite use of laxatives After 5 years: -50% are recovered and no longer taking laxatives After 10 years: 80% are recovered and no longer taking laxatives A delay in initial medical treatment for >3 months from symptom onset correlates with longer duration of symptoms
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Online Resources “The Poo in You”: 6 minute video available on Youtube or at www.gikids.org “I go potty”: free app with potty training tips Squatty Potty: www.squattypotty.com (lol unicorn) Pedia-lax (www.pedia-lax.com) Provider resources: Poop journal Product information
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Abdominal Pain
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Diagnosis Unless proven otherwise, all pediatric abdominal pain is acid reflux If it is not GER/reflux, it is most likely constipation
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History and Physical Infants and toddlers: There is no symptom or symptom complex that is diagnostic of GERD or predicts response to therapy Children and adolescents: History and physical examination may be sufficient to diagnose GERD if the symptoms are typical
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Diagnostic Testing pH probe and pH/impedance probe testing May be useful to correlate symptoms (eg, cough, chest pain) with acid reflux episodes and to select those infants and children with wheezing or respiratory symptoms in whom GER is an aggravating factor Sensitivity, specificity and clinical utility for diagnosis and management of possible extraesophageal complications of GER are not well established
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Diagnostic Testing Esophageal manometry Useful to confirm a diagnosis of achalasia or other motor disorder of the esophagus that may mimic GERD Not useful to diagnose GERD Endoscopy and biopsy Important to identify or rule out other causes of esophagitis (eosinophilic esophagitis), and to diagnose and monitor Barrett esophagus
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Diagnostic Testing Barium contrast radiology (UGI) Not useful for the diagnosis of GERD Useful to confirm or rule out anatomic abnormalities of the upper gastrointestinal tract that may cause symptoms similar to those of GERD Nuclear scintigraphy (gastric emptying scan) Not useful for the diagnosis of GERD Recommended only in individuals with symptoms of gastric retention
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Diagnostic Testing Esophageal and gastric ultrasonography Not recommended for the routine evaluation of GERD in children Abdominal US is useful for evaluating pyloric stenosis in infants
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Diagnostic Testing Tests on ear, lung and esophageal fluids Evaluation of middle ear or pulmonary aspirates for lactose, pepsin, or lipid-laden macrophages have been proposed as the tests for GERD. No controlled studies have proven that reflux is the only reason these compounds appear in ear or lung fluids, and no controlled studies have shown that the presence of these substances confirms GER as the cause of ear, sinus, or pulmonary disease
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Diagnostic Testing Empiric trial of acid suppression as a diagnostic test Expert opinion suggests that in an older child or adolescent with typical symptoms suggesting GERD, an empiric trial of PPIs is justified for up to 4 weeks Symptom improvement does not confirm a diagnosis of GERD There is no evidence to support an empiric trial of acid suppression as a diagnostic test in infants and young children where symptoms suggestive of GERD are less specific
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Treatment Lifestyle changes Infant: reflux precautions (hold upright x 20 minutes after eating, feeding smaller volumes more frequently), elemental formulas, thickening formula Children and adolescents: Prone or left-side sleeping position and/or elevation of the head of the bed may decrease GER. There is no evidence to support the routine elimination of any specific food for management of GERD. In adults, obesity, large meal volume, and late night eating are associated with symptoms of GERD.
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Treatment Pharmacologic therapies: Histamine-2 Receptor Antagonists Tagamet (cimetidine): 10-15 mg/kg/dose 4x/day, before meals and at bedtime Zantac (ranitidine): 3-5 mg/kg/dose 2-3x/day, before meals and at bedtime Rapid onset of action, useful for on-demand treatment. Tachyphylaxis (tolerance) is a drawback to chronic use.
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Treatment Pharmacologic therapies: Proton Pump Inhibitors: Prilosec (omeprazole): 0.7 – 3.3 mg/kg/day, 1-2x/day Prevacid (lansoprazole): 1.4 mg/kg/day, 1-2x/day Protonix (pantoprazole): 1 mg/kg/day, max 40 mg/day Aciphex (rabeprazole): Pediatric doses not defined Nexium (esomeprazole): Pediatric doses not defined PPI’s are superior to H2RAs. No PPI has been approved for use in infants younger than 1 year of age.
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Treatment Pharmacologic therapies: Prokinetic therapy: Reglan (metoclopramide): 0.1 mg/kg/dose 4x/day Propulsid (cisapride): 0.2 mg/kg/dose 4x/day Erythromycin (eryped): 3-5 mg/kg/dose, 3-4x/day Bethanechol (urecholine): 0.1-0.3 mg/kg/dose 3-4x/day Domperidone: Pediatric doses not defined There is insufficient evidence of clinical efficacy to justify the routine use of metoclopramide, erythromycin, bethanechol, cisapride or domperidone for GERD.
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Treatment Pharmacologic therapies: Buffering agents: Carafate (sucralfate): 40-80 mg/kg/day, 4x/day PRN Sodium alginate (algin): 0.2 – 0.5 mL/kg/dose, 3-4x/day Useful on demand for occasional heartburn. Chronic use of buffering agents or sodium alginate is not recommended for GERD because some have absorbable components that may have adverse effects with long-term use
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Treatment Surgical therapy: Nissen Fundoplication Indications for surgery Failure of optimized medical therapy Dependence on long-term medical therapy Pulmonary aspiration of refluxate Respiratory complications (asthma, frequent pneumonia) Before surgery it is essential to rule out non-GERD causes of symptoms and ensure that the diagnosis of chronic-relapsing GERD is firmly established.
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Red Flags Fever:
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Red Flags Fever: infection, inflammatory bowel disease (IBD)
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Red Flags Fever: infection, inflammatory bowel disease (IBD) Hematochezia:
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Red Flags Fever: infection, inflammatory bowel disease (IBD) Hematochezia: milk protein allergy (infants), IBD
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Red Flags Fever: infection, inflammatory bowel disease (IBD) Hematochezia: milk protein allergy (infants), IBD Weight loss:
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Red Flags Fever: infection, inflammatory bowel disease (IBD) Hematochezia: milk protein allergy (infants), IBD Weight loss: IBD, gastroparesis
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Red Flags Fever: infection, inflammatory bowel disease (IBD) Hematochezia: milk protein allergy (infants), IBD Weight loss: IBD, gastroparesis Localized pain, right side:
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Red Flags Fever: infection, inflammatory bowel disease (IBD) Hematochezia: milk protein allergy (infants), IBD Weight loss: IBD, gastroparesis Localized pain, right side: appendicitis
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Case Study Ashley, 6 year old female, 19.4 kg Presenting symptoms in GI clinic: Constipation since infancy, currently taking Miralax ½ capful daily Abdominal pain for 12 months, better with Miralax, has been taking Nexium 5 mg daily x 9 months.
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Diagnostic Evaluation Labs: CBC w/d&p, Chem 10, TSH, T-4, Celiac panel, IgA, Immunocap, H. pylori stool Results: normal/negative except for Immunocap showed a Class 2 reaction to milk KUB performed: “Moderate stool in the right colon, transverse colon, and sigmoid colon” Anorectal manometry: normal, negative for HD
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Diagnosis?
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Diagnosis Constipation
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Plan of Care: Clean out: Miralax 1 capful in 8 oz of water or juice, drink 4 oz every 15 minutes until stool comes out clear. Maintain clear liquid diet during clean out, return to regular diet after clean out completed Daily laxative regimen after clean out: Miralax 1 capful in 8 oz of liquid daily, may titrate up or down to keep daily stools soft but formed Trial of milk protein allergy diet
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Follow Up Abdominal pain persisted Continue laxative regimen Continue milk allergy diet Increase Nexium to 20 mg daily Scheduled upper endoscopy to further evaluate persistent abdominal pain. Results: negative for Celiac disease and H. pylori, two small ulcerations found in the stomach. Imipramine and Carafate prescribed based on endoscopy findings.
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Follow up after Upper Endoscopy Abdominal pain persisted Continue laxative regimen Continue milk allergy diet Increase Nexium 20 mg, 2x/day Discontinue Imipramine and start Nortriptyline Continue Carafate
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Next Follow Up Visit Abdominal pain persisted Presents with new symptoms: Weight loss Vomiting x 3 weeks
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New Diagnosis?
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New Diagnosis Gastroparesis Gastric emptying scan performed Results: showed delayed gastric emptying of a solid food meal. (153 minutes vs. normal of 90 minutes) Erythromycin started, 3 mg/kg/dose, 3x/day No improvement in abdominal pain and vomiting Erythromycin increased to 5 mg/kg/dose, 3x/day No improvement in abdominal pain and vomiting Erythromycin increased to 10 mg/kg/dose, 3x/day
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Follow Up Abdominal pain improved but not resolved Vomiting resolved Gaining weight Plan: KUB: showed “moderate to large amount of stool Repeat clean out Continue with all other medications, no change
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Follow Up Abdominal pain resolved after repeat upper endoscopy with pyloric sphincter botox injection. Patient was seen smiling and comfortable in GI clinic for the first time! Continued on aggressive medication regimen: Daily laxative (Miralax) Daily PPI (Nexium) Daily Prokinetic (Erythromycin)
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Thank you