Chronic Constipation and Encopresis

Vctor M. Pieiro, M.D. Uniformed Services University Bethesda, Maryland

Definition and Frequency

Constipation is a symptom, not a disease Stools are small, hard or infrequent 3% of outpatient pediatric visits 10-25% prevalence in Pediatric GI practice

Constipation
Most common GI outpatient problem
May start at any age

Rarely due to structural abnormality or systemic disease Children DO NOT outgrow it spontaneously Prognosis is good if treated appropriately

Normal Bowel Habit

Stool frequency
Stool weight Transit time

Pre school children

QOD - TID (95%)

25 gms 33 hrs

Toilet training

ages 2-3 yrs.

Colonic Motility
Colon has complex motility patterns Colonic contents moved to the cecum by waves of "antiperistalsis" Colonic haustrations prominent in transverse and descending colon Giant migrating contractions originate in transverse colon and rapidly reach the rectum (gastrocolic reflex)

Mechanisms of Defecation
Inflation Reflex
Seen after age 2 Distension of rectum Stimulus sensory nerves

Conscious awareness
Transient relaxation of external anal sphincter (EAS)

Mechanisms of Defecation
Rectosphincteric Relaxation Reflex

Distension of rectum
Sensory nerves (via myenteric plexus) Inhibition of smooth muscle internal anal sphincter Relaxation of IAS

Chronic Idiopathic Constipation

Male predominance 1.5:1

Age of onset Event at onset

Large stools

0-1 yr 25% 0-5 yr 70% 30%

75%

Withholding behaviors
Failed toileting

40%
30%

Clinical Presentation
Family history 10-50%

Rectal bleeding
Enuresis/UTIs Abdominal Pain Psychologic problems Rectal prolapse Poor appetite Previous therapy

25%
15% 10-50% 20% 3% 26% 90%

Clinical Presentation
Physical examination

Abdominal distention
Abdominal mass

20%
30-50%

Fecal impaction
Weight < 5%

40-50%
0-10%

Anorectal Manometry
Proximal rectal balloon to distend the rectum Pressure sensors used to measure IAS and EAS
Distention of rectum triggers the Inflation and Rectosphincteric relaxation reflexes

Pathophysiology
I. Resting anal sphincter pressure Increased, normal or decreased II. Rectosphincteric relaxation reflex Critical volume ( minimal volume of rectal distention required to elicit the relaxation reflex) is often increased

Pathophysiology II
III. Rectal Sensitivity - Conscious Awareness

Threshold volume (volume required to produce conscious awareness) is often increased

In encopresis IAS relaxation occurs at volumes that do not stimulate conscious awareness

Pathophysiology III
IV. External anal sphincter Paradoxical EAS contraction (unconscious EAS contraction during defecation) in severe constipation

V. Expulsion failure
Patients with severe constipation and encopresis may have an inability to defecate balloons

Potentiation of Risk for Encopresis

Stage I Infancy and Toddler Years Simple constipation Congenital anorectal problems

Parental overreaction
Coercive medical interventions

Potentiation of Risk for Encopresis

Stage II 2 to 5 years

Psychosocial stresses Coercive or permissive training Toilet fears Painful or difficult defecation

Potentiation of Risk for Encopresis

Stage III Early School Years
Avoidance of school bathrooms

Prolonged gastroenteritis
Attention deficit disorder

Frenetic life-styles
Psychosocial stress

Differential Diagnosis

Medical
Hypothyroidism
Hypokalemia

Diabetes insipidus
RTA

Hypercalcemia
Uremia

Botulism
CNS disorders

Depression

Anorexia nervosa

Gastrointestinal Disorders
Intestinal Pseudo-obstruction
Cystic fibrosis

Crohn's disease
Celiac disease

Drugs and Toxins

Anticholinergics Iron

Anticonvulsants
Opiates

Bismuth
Lead

Antidepressants

Barium

Anatomic
Anorectal anomalies

Spinal cord injury

Sacrococcygeal teratoma

Hirschsprung's disease
Meningomyelocele

Anterior Anal Displacement

Anterior ectopic anus Anal canal + IAS anteriorly located EAS in normal position

Anteriorly located anus

Anal canal + both sphincters anteriorly located

Anterior Anal Displacement

Rectal exam Posterior angulation of anal canal Posterior shelf

Treatment
Often conservative

Surgical repair if severe

Hirschsprung's Disease
Congenital Aganglionosis of colon

Rectosigmoid colon
Transverse/Ascending Total aganglionosis Ultrashort

80%
15% 5% Rare

Hirschsprung's Disease
Barium enema Distal narrowed segment, transition zone, "saw-toothed" contractions Anorectal manometry Lack of rectosphincteric relaxation reflex

Rectal biopsy
Diagnostic (adequate specimen, expert pathologist)

Encopresis
Weissenberg - 1926

Involuntary passage of whole bowel movements in the underwear or on abnormal place

Now commonly used synonymously with fecal incontinence or soiling

Treatment
Must explain the pathophysiology of the problem

Improves compliance with therapy

Alleviates the guilt and blame the parents may feel Decreases embarrassment child is experiencing

Treatment
Three Stages
Education

Initial Catharsis (Whoosh)

Maintenance

Catharsis
Day 1 Magnesium citrate 5-10 oz. P.O. Days 1-3 Mineral oil enema 3-4 oz. PR Days 1-3 Fleet enema 2-4 oz. PR

Days 2-4 Dulcolax 5-10 mg. P.O. QD

Maintenance Regimen
High Fiber Diet
MOM 0.5-1 ml/kg/dose BID Mineral oil 0.5-1 ml/kg/dose BID Behavior modification (Toilet training)

Follow up visits every month

Anal Position Index

Ratio of anus-fourchette distance to coccyx-fourchette distance (scrotum in males)
Normal Ratios A/B > 0.34 in females > 0.46 in males

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Diagnostic Evaluation
Complete History and Physical Examination Laboratory Studies CBC, ESR, U/A, Urine culture Stool culture, O & P, occult blood

Serum glucose, calcium, phosphorus

Thyroid function studies

Diagnostic Evaluation
Radiographic Studies Abdominal plain film, BE Special diagnostic Studies Rectal suction biopsy

Anorectal manometry Indicated Studies

UGI/small bowel series Proctosigmoidoscopy, colonoscopy Pelvic MRI