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Program MCPS/MRCGP/CEFM CME ©

Course Paediatrics

Module GI

Topic Constipation

Credit Hours 1 CME credit hour

Total Educational hours 2 educational hour

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

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Prof. Nasir Shah
MCPS, FCPS, MRCGP [INT], FRCGP [INT]

Dean Family Medicine Faculty, College of Physicians and

Surgeons Pakistan

Convener National Family Medicine Committee of

Pakistan

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

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CONSTIPATION: BACKGROUND ®
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1. Concern about bowel function is historic
2. A normal bowel pattern is thought to be a sign of good health
3. No uniform definition of childhood constipation
4. Healthcare providers definitions very different from parents

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

CONSTIPATION: BACKGROUND ®
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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

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CONSTIPATION: DEFINITION ®
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• 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.

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

CONSTIPATION: DEFINITION ®
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• The Paris Consensus on Childhood Constipation Terminology
(PACCT) defines constipation as:
• "a period of 8 weeks with at least 2 of the following
symptoms:
a. Defecation frequency less than 3 times per week
b. Fecal incontinence frequency greater than once per week
c. Passage of large stools that clog the toilet
d. Palpable abdominal or rectal fecal mass
e. Stool withholding behavior
f. Painful defecation

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

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CONSTIPATION: ASSOCIATED SYMPTOMS ®
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Symptoms associated with defecation:

1. Distress on stooling or anal pain

2. Bleeding associated with hard stool
3. Straining, hernia
4. Poor appetite or abdominal pain that improves after stool passed

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

CONSTIPATION: SERIOUS UNDERLYING CONDITIONS ®

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Serious Underlying cause: Stigmata other than constipation

1. Hirschsprung’s disease
2. Anorectal abnormalities
3. Neurological conditions
4. Hypothyroidism
5. Abdominal tumors
6. Celiac disease

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

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CONSTIPATION: D/D ®
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• Underlying cause: Rare
• Underlying cause: Stigmata other than constipation
• Practical purposes: D/D is;
- Hirschsprung disease
- Functional constipation
• History and physical examination are helpful

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

FUNCTIONAL CONSTIPATION VERSUS

HIRSCHSPRUNG DISEASE
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• History
• Passing first bowel movement after birth is important
• Usually, children with Hirschsprung disease do not pass
meconium during the first 36 hours
• Diagnosed with constipation within first 4-6 months of life

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

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FUNCTIONAL CONSTIPATION ®
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• In young infants: At the time of a dietary transition

• In toddlers: Near the time of toilet training

• In older children: At the time of school entry, because they

refuse to defecate while they are at school

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

VOLUNTARY WITHHOLDING ®
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• Precipitated by painful bowel movements with resultant
voluntary withholding of stool

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

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CONSTIPATION: OVERFLOW SOILING ®
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• Overflow soiling (children >1y)

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

CONSTIPATION: EXAMINATION ®
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• The most important: Digital rectal examination
• Use pinkie finger
• Note:
1. Size of the anal canal
2. Size of the rectum
3. Intrarectal masses
4. If the rectum is empty or filled with stool
5. Consistency of the stool

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

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FUNCTIONAL CONSTIPATION VERSUS
HIRSCHSPRUNG DISEASE ®
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Hirschsprung disease:
• Rectum is typically quite small and empty of stool
• Following the digital examination, may have a gush of liquid
stool, because the functional obstruction has transiently been
relieved

Functional constipation:
• Rectum is generally enlarged
• Stool is present just beyond the anal verge

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

EXAMINATION: ANUS ®
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• Anal fissures
• Anal wink reflex: stroke the perianal skin with a pin or probe:
Visible puckering at the anal margin
• Absence of anal wick: neurological deficit

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

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CONSTIPATION: INVESTIGATIONS ®
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• Diagnosed clinically
• Laboratory studies are generally unnecessary
• Laboratory studies only if suspecting underlying condition

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

CONSTIPATION: INVESTIGATIONS ®
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• Supine X-ray abdomen

• Assesses colonic fecal burden

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Constipation

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