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Constipation Diseases PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Constipation" by Dale Lee, MD and Kristin Fiorino, MD.
This medical PowerPoint presentation talks about Constipation, infrequent bowel movements or difficulty passing stools. It is a common gastrointestinal problem that can be caused by a variety of factors, including a lack of fiber in the diet, inadequate water intake, certain medications, stress, and physical inactivity.

Tags : Constipation, infrequent bowel movements, gastrointestinal problem, Digestive System, Digestive System PowerPoint presentation

Published on : Mar 27, 2023 | Views : 2114 | Downloads : 7

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Slide 1-

Constipation Dale Lee, MD Kristin Fiorino, MD The Children’s Hospital of Philadelphia Reviewed by Christine Waasdorp Hurtado, MD of the Professional Education Committee
Slide 2-

Case 4 year old female presenting with painful, infrequent bowel movements (3x/week) without blood, occasional stool leakage onto underwear, decreased appetite. No fever, vomiting, normal growth parameters, no weight loss Thoughts?
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Objectives Know the differential diagnosis of constipation Differentiate functional vs. organic constipation Understand the pathophysiology of encopresis Learn treatment strategies for constipation
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“A regular pattern of defecation is considered by many to be a sign of good health” Epidemiology: 3 million Americans/year receive medications for constipation from their physicians (US population estimate: 314 million) Constipation: 3% visits to general pediatrician 10-25% visits to pediatric GI Croffie JM. Pediatric Gastrointestinal Disease. Fourth ed; 2004. Sonnenberg A. Dis Colon Rectum 1989. Loening-Baucke V. Gastroenterology 1993. Fleisher PR. Pediatric Annals 1976.
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Definition of constipation: “A term used to describe the subjective complaint of passage of abnormally delayed or infrequent passage of dry, hardened feces”1 Hard stools Large stools Infrequent stools Discomfort with stools 1Merriam-Webster dictionary *Formal NASPGHAN definition specifies minimum 2 week duration
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Frequency Normal defecation Infants: 4 per day (range 1 - 7x/day) Children (2 yo): 1.2 - 2x day Adults: 3 per week - 3 per day Pattern attained by ~4 yo Croffie JM. Pediatric Gastrointestinal Disease. Fourth ed; 2004. Lemoh JN. Arch Dis Child 1979. Weaver LT. Arch Dis Child 1984. Weaver LT. J Pediatric Gastroenterology Nutrition 1988.
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History and Physical examination Red flags: History: fever, anorexia, weight loss, vomiting, bloody diarrhea, constipation since infancy Physical exam: abnormal perianal exam (erythema, fistula), abnormal anal tone, absence of anal wink, sacral tuft of hair
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Differential diagnosis: constipation Non-organic Developmental Infant dyschezia Cognitive Attention-deficit disorders Situational Toilet training Toilet phobia School bathroom avoidance Sexual abuse Constitutional Colonic inertia Genetic predisposition Reduced stool volume and dryness Low fiber in diet Dehydration Underfeeding or malnutrition Organic Abnormalities of the colon and rectum Spinal cord lesions Neuropathic lesions Metabolic conditions Systemic disorders Drugs
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Organic causes of constipation Abnormalities of the colon and rectum Chronic intestinal pseudoobstruction Anal stenosis Anal/colonic stricture –post NEC/IBD Ectopic anus Spinal cord lesions Spina bifida, Meningomyelocele Sacral agenesis Tethered cord Tumors Neuropathic lesions Hirschsprung disease Intestinal neuronal dysplasia Metabolic Hypothyroidism Hypo/hyper-calcemia Hypokalemia Uremia Systemic disorders Celiac disease Cystic fibrosis Diabetes mellitus Panhypopituitarism Dermatomyositis, scleroderma Autoimmune disorders MEN, pheochromocytoma Lead toxicity Drugs Analgesics Anticholinergics Iron Antacids (esp Ca2+ containing) NSAIDs Psychotropics Sympathomimetics
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Medical work-up History and physical exam Labs: Serum Calcium TSH/T4 Celiac panel Lead level CBC Imaging Manometry
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Imaging studies KUB: to establish fecal impaction in child refusing rectal exam or in obese child Un-prepped barium enema (to look for transition zone) MRI lumbosacral spine (to evaluate for tethered cord) Sitz marker study (capsule contains 24 markers) Passage of 80%: normal transit Scattered throughout: colonic inertia In rectum: outlet dysfunction Croffie JM. Pediatric Gastrointestinal Disease. Fourth ed; 2004. http://www.sitzmarks.com/howtointerpretasitzmarkstest.aspx
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Other Studies Anorectal manometry can identify: Increased rectal sensory threshold Paradoxical contraction of external anal sphincter and puborectalis muscles Failure of relaxation of internal sphincter Anal sphincter electromyography* Evaluate activity of external anal sphincter and puborectalis muscle Rectal biopsy Hirschsprung disease – absence of ganglion cells in submucosa * To evaluate external anal sphincter and puborectalis muscle; can be used for biofeedback
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Manometry Croffie JM. Pediatric Gastrointestinal Disease. Fourth ed; 2004.
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Making a diagnosis If history and physical examination (+/- labs, imaging, manometery) are not consistent with organic disease, functional constipation can be diagnosed.
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Rome III criteria: Functional Constipation H3a. Functional Constipation: Diagnostic criteria* Must include two or more of the following in a child with a developmental age of at least 4 years** with insufficient criteria for diagnosis of IBS: 1. Two or fewer defecations in the toilet per week 2. At least one episode of fecal incontinence per week 3. History of retentive posturing or excessive volitional stool retention 4. History of painful or hard bowel movements 5. Presence of a large fecal mass in the rectum 6. History of large diameter stools which may obstruct the toilet *Criteria fulfilled at least once per week for at least 2 months prior to diagnosis **Criteria for functional constipation in infant up to 4 years of age is similar
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Defecation Dynamics Normal ano-rectal angle: 85-105 degrees Stool in anorectum: temporary relaxation of internal anal sphincter The Decision: Allow escape? Hold in? Voluntary Muscle Relaxation: - Puborectalis muscle - External anal sphincter Croffie JM. Pediatric Gastrointestinal Disease. Fourth ed; 2004.
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Pathogenesis and Mechanism of Constipation Causes: Decrease in propulsive force Impaired rectal sensation Functional outlet obstruction Behavioral withholding Constipation Cycle: Pain/irritation  retention  rectum accommodates  atonic/desensitized rectum  larger volumes stool rectum dilates and anal canal shortens  stool escape (encopresis)
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Triggers Usually acute episode precedes a chronic course: i.e. diet change—human milk to cow’s milk (higher protein to carbohydrate ratio; cow’s milk protein allergy) Toddlers: toilet training and pattern of stool retention Older children: retentive pattern due to inconvenient or uncomfortable situations (i.e. school)
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Fecal Incontinence: Encopresis Definition: incontinence of stool not resulting from organic defect/illness Fecal incontinence followed by expulsion of megastool Incontinence due to organic pathology is not the same! Mean age: 7.4 - 9 yo Male/Female: 2 to 1 Parents often do not understand why their child is soiling themselves Levine MD. Pediatrics 1975. Croffie JM et al. Gastroenterology 1995.
Slide 20-

Most common condition that must be differentiated from idiopathic constipation? http://uvahealth.com/services/childrens-hospital/conditions-treatments/22828
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Most common condition that must be differentiated from idiopathic constipation? Hirschsprung disease Segmental colonic aganglionosis Absence of ganglion cells in the submucosal (Meissner) and myenteric (Auerbach) plexuses in the distal colon Prevalence 1 in 5000 live births Male/female ratio: 4 to 1 Association with trisomy 21 and other chromosomal abnormalities Presentation varies: Severe enterocolitis in infancy Abdominal distension, feeding refusal, obstruction Fecal impaction and FTT Exam: empty rectum, gush of air/liquid stool **In short/ultra-short segment Hirschsprung, diagnosis may not be made until late in life Imseis E. Pediatric Gastrointestinal Disease. Fourth ed; 2004.
Slide 22-

Medicines for Treatment of Constipation Osmotic Dose Side Effects Lactulose (70% solution) 1-3 ml/kg/day Flatulence, abd cramps Sorbitol (70% solution) 1-3 ml/kg/day (same as lactulose) Magnesium hydroxide 0.5-3 ml/kg/day Hyper-Mg, hypo-phosp Magnesium citrate 1-3 ml/kg/d (>6yo: 150ml/d) Hyper-Mg, hypo-phosp Polyethylene glycol 1-1.5 g/kg/day --- Lubricant Mineral oil 1-3 ml/kg/day Aspiration pneumonia Stimulant Senna 2.5-7.5 ml/d (2-6 yo) Idiosyncratic hepatitis, melanosis coli Bisacodyl 5-10 mg/d Abd pain/diarrhea, hypokalemia Glycerin suppository --- --- Evaluation and Treatment of Constipation in Infants and Children: Recommendations of NASPGHAN. JPGN. 2006.
Slide 23-

Treatment of idiopathic constipation Disimpaction Oral medications: mineral oil, polyethylene glycol Rectal disimpaction: phosphate soda enemas, saline enemas, mineral oil enemas Manual disimpaction Maintenance Therapy Diet: ↑ fluids; balanced diet with whole grains, fruits, vegetables, chia, flax seed Behavior modification: regular toilet-sitting, reward system, possible psychology referral Laxatives
Slide 24-

Refractory constipation Consider GI clinic referral Gastroenterologist may consider: Maintenance rectal therapy Medications and behavioral therapy Referral for surgical intervention Anterograde enemas (appendicocecostomy, sigmoid button) Diverting ostomy Cecostomy Croffie JM. Pediatric Gastrointestinal Disease. Fourth ed; 2004.
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References Croffie JM, Fitzgerald JF. Hypomotility disorders. In: Walker A, editor. Pediatric Gastrointestinal Disease. Fourth ed. Ontario: Decker Inc; 2004. Sonnenberg A, Koch TR. Epidemiology of constipation in the United States. Dis Colon Rectum 1989;32:1–8. Loening-Baucke V. Chronic constipation in children. Gastroenterology 1993;105:1557–64. Fleisher PR. Diagnosis and treatment of disorders of defecation in children. Pediatric Ann 1976;5:71–101 Lemoh JN, Brooke OG. Frequency and weight of normal stools in infancy. Arch Dis Child 1979;54:719–20. Weaver LT, Steiner H. The bowel habit of young children. Arch Dis Child 1984;59:649–52. Weaver LT, Ewing G, Taylor LC. The bowel habit of milk-fed infants. J Pediatric Gastroenterology Nutrition 1988;7:568–71. Levine MD. Children with encopresis: a descriptive analysis. Pediatrics 1975;56:412–6. Croffie JM, Macapagal M, Chong SKF, Fitzgerald JF. Chronic constipation and/or encopresis in children—a study of treatment outcome. Gastroenterology 1995;108 Suppl:A10. Evaluation and Treatment of Constipation in Infants and Children: Recommendations of NASPGHAN. JPGN. 2006; 43: e1-e13. Loening-Baucke V. Constipation and Fecal Incontinence. Pediatric Gastrointestinal and Liver Disease. Fourth ed. Philadelphia: Saunders; 2011. Imseis E. Gariepy CE. Hirschsprung Disease. In: Walker A, editor. Pediatric Gastrointestinal Disease. Fourth ed. Ontario: Decker Inc; 2004.