KONSTIPASI (medscape)

Pendahuluan

Anatomy
Bowel motility is one of the most complex and sophisticated functions in the human body. The
colon absorbs water and functions as a reservoir. Liquid waste delivered by the small bowel
into the cecum becomes solid stool in the descending and sigmoid colon. The colon has a slow
motility; its peristalsis seems to be less active in the distal portions of the colon. Every 24-48
hours, the rectosigmoid develops active peristaltic waves that indicate that it must be emptied.
This is perceived by the individual, who then has the capacity to voluntarily retain the stool or to
empty it, depending on social circumstances.

Definitions
OBSTIPASI: Intractable constipation (dorland)

For practical clinical purposes, constipation is generally defined as infrequent defecation, painful
defecation, or both. In most cases, parents are worried that their child's stools are too large, too
hard, not frequent enough, and/or painful to pass.
The North American Society of Gastroenterology, Hepatology, and Nutrition (NASPGHAN)
defines constipation as "a delay or difficulty in defecation, present for 2 weeks or more, and
sufficient to cause significant distress to the patient."[3]
The Paris Consensus on Childhood Constipation Terminology (PACCT) defines
constipation as:
"a period of 8 weeks with at least 2 of the following symptoms:
 defecation frequency less than 3 times per week,
 incontinence frequency greater than once per week, (frekuensi BAB tidak teratur lebih
darai seminggu)
 passage of large stools that clog the toilet, (menyumbat toilet)
 palpable abdominal or rectal fecal mass,
 stool withholding behavior,
 or painful defecation."[4]
Nelson: Constipation is defined by a delay or difficulty in defecation that has been present for 2
wk or longer.

Jenis2 :
A. Functional constipation, also known as idiopathic constipation or fecal withholding, can
usually be differentiated from constipation secondary to organic causes on the basis of a
history and physical examination. Konstipasi fungsional (idiopatik):

 biasa pada anak >2 tahun

 dapat terjadi karena nyeri ketika peristaltik usus --> anak menahan feses secara volunter
biar ga sakit.

functional constipation typically starts after the neonatal period. The constipation usually
develops after the passage of painful bowel movements with voluntary withholding of feces to
avoid the painful stimulus. Perianal inflammation from milk protein allergy may initiate the
painful stimuli. When children have the urge to defecate, typical behaviors include contracting
the gluteal muscles by stiffening the legs while lying down or holding onto furniture while
standing. Some children will squat or hide while passing stool. Caregivers may misinterpret
these activities as straining. In functional constipation, daytime encopresis is common, and some
children will have a history of blood in the stool noted with the passage of a large bowel
movement. Findings suggestive of underlying pathology include failure to thrive, weight loss,
abdominal pain, vomiting, or persistent anal fissure or fistula.

B. Konstipasi Organik: ada kelainan organik

 Polip, Ca kolorektal, striktura ani

 Hirschsprung disease, or congenital aganglionic megacolon, is caused by abnormal
innervation of the bowel, beginning in the internal anal sphincter and extending
proximally to involve a variable length of gut. Hirschsprung disease is the most
common cause of lower intestinal obstruction in neonates, with an overall incidence
of 1/5,000 live births.

TABLE 329-1 -- Distinguishing Features of Hirschsprung Disease and Functional

Constipation
VARIABLE FUNCTIONAL (ACQUIRED) HIRSCHSPRUNG DISEASE
HISTORY
VARIABLE FUNCTIONAL (ACQUIRED) HIRSCHSPRUNG DISEASE
Onset of After 2 yr of age At birth
constipation
Encopresis Common Very rare
Failure to thrive Uncommon Possible
Enterocolitis None Possible
Forced bowel Usual None
training
EXAMINATION
Abdominal Uncommon Common
distention
Poor weight gain Rare Common
Anal tone Normal Normal
Rectal examination Stool in ampulla Ampulla empty
Malnutrition None Possible
LABORATORY
Anorectal Distention of the rectum causes No sphincter relaxation or
manometry relaxation of the internal sphincter paradoxical increase in pressure
Rectal biopsy Normal No ganglion cells, increased
acetylcholinesterase staining
Barium enema Massive amounts of stool, no Transition zone, delayed evacuation
transition zone (>24 hr)

The following image is an abdominal radiograph of a child with constipation.

ANAMNESIS

DIAGNOSIS BANDING

 Hirschsprung disease (ie, congenital megacolon),

 spinal or neuromuscular abnormalities (eg, spinal muscular atrophy, tethered cord, Currarino
triad [rectal stenosis, hemi sacrum, presacral mass], cerebral palsy [static encephalopathy]),
 hypothyroidism,
 anal stenosis,
 imperforate anus with fistula,
 allergy or sensitivity to cow's milk,.

Fortunately, in most cases in which an underlying condition causes constipation, other

stigmata of the disorder point to diagnosis. For example, constipation is rarely the only
symptom of hypothyroidism.