Dr Hodan Ahmed

Dept of Pediatrics and Child Health

Amoud Medical School, AU

CONSTIPATION IN CHILDREN
Definitions

 "a delay or difficulty in defecation, present for 2

weeks or more, and sufficient to cause significant
distress to the patient”
 "a period of 8 weeks with at least 2 of the
following symptoms: defecation frequency less
than 3 times per week, fecal incontinence
frequency greater than once per week, passage of
large stools that clog the toilet, palpable
abdominal or rectal fecal mass, stool withholding
behavior, or painful defecation.
Rome III criteria

 <2 motions/wk
 >1 fecal incontinence/wk
 Painful hard bowel movement
 Large faecal mass in rectum
 Large stool obstructing toilet

 2 or more of above
General practical definition

 infrequent defecation <3/wk

 painful defecation
 In most cases, parents are worried that their
child's stools are too large, too hard, not
frequent enough, and/or painful to pass
 Encopresis

 Term first used in 1926 to suggest similarity

with ‘enuresis’ for wetting
 Inappropriate passage of normal stool
 Stool passed in pants or deposited ‘elsewhere’
(where it can be found!)
 Often associated with other behavioural
problems
Epidemiology

 Reported prevalence rates between 1-30%.

principal complaint in 3-5% of all visits to
pediatric outpatient clinics and as many as
35% of all visits to paed gastroenterologists.
What is normal ?

 The frequency of stools in most children

decreases from a mean of four per day in the
first week of life to 1.7 per day by the age of 2
years.
 Intestinal transit time from mouth to rectum
increases from 8 hours in the first month of
life to 16 hours by 2 years of age to 26 hours
by the age 10.
Normal control of bowels
 Normal continence is maintained by the
resting tonicity of the internal anal sphincter
 Enhanced by contraction of the puborectalis
muscle, which creates a 90-degree angle of
rectum to the anal canal.
 When >15 cc of stool enters rectum, stretch
receptors and nerves in the intramural plexus
are activated.
 Normal emptying of bowels

 Relaxation of the sphincter allows the stool to

reach the external anal sphincter and the urge
to defecate is signaled.
 If the child relaxes the external anal sphincter,
squats to straighten the anorectal canal, and
increases intra-abdominal pressure the
rectum is evacuated of stool.
Normal defecation
PATHOGENESIS OF FUNCTIONAL
CONSTIPATION
Factors ppt
-Changes in
routine Voluntary withholding
-Changes in diet
Prolonged fecal stasis
-Stressful event Re-absorption of fluids
 in size & consistency
-Postponing
defecation-TV,
More pain
-Too early toilet
training Rectum habituates to
-ADHD stimulus of enlarged stool
Fecal soiling(30%)
Causes of constipation
 Functional constipation
 Prune-belly syndrome
 Hirshsprung Disease

Muscular
 Spinal muscular atrophy
 Neurofibromatosis

Neurological
 Currarino's triad (rectal
 Neuronal intestinal stenosis, hemi sacrum,
dysplasia presacral mass)
 Cerebral palsy (static
encephalopathy)  Celiac disease
 Tethered cord  Cow's milk intolerance

Metabolical
 Mitochondrial disorders
 Imperforate Anus  Hypercalcemia
 Anal stenosis,  Hypokalemia
 Anterior displacement of  Hypothyroidism
the anus  Drugs
Hirschsprung disease
 Hirschsprung disease or aganglionosis occurs in 1 in
5,000 births. M:F ratio is 4:1
 The diagnostic lack of ganglion cells in the
myenteric and submucosal plexus of the bowel wall
extends proximally from the internal anal sphincter.
 In among 80% of the involved children, the
aganglionic segment does not extend above the
sigmoid.
Hirschsprung disease
 Difficulty with evacuation is present from
birth;
 Meconium passage delayed > 48 hours of life
in 40% of involved infants.
 Recurrent abdominal distension, emesis,
failure to thrive, and acute enterocolitis allow
diagnosis of 60% of patients by 3 months of
age.
Neuronal dysplasia

 Neuronal dysplasia is assoc with increased

numbers of ganglion cells
(hyperganglionosis) in the lower colon.
 In childhood- presents with variable
constipation/pseudo-obstruction.
Hypoganglionosis

 Reduced numbers of ganglion cells

(hypoganglionosis) usually is an acquired
disease of ganglion cell destruction seen in
Chagas disease or paraneoplastic syndrome.
Other neuromuscular disorders

 Neuronal disorders
 Any damage to corticospinal pathways - lumbosacral
myelomeningocele, cerebral palsy
Muscular disorders
 Anorectal dysfunction after operative pullthrough
surgery for high imperforate anus or colectomy.
 Prolonged diarrhea (pelvic floor muscles fatigue)
 Muscular dystrophy
 Prune belly
 Obstructive causes
 Congenital anterior anus
 Anterior ectopic anus is defined by a measurable
displacement of the anal opening based on the ratio of
the anus-to-fourchette to the coccyx-to-fourchette being
less than 0.34 in females and less than 0.46 in males.
 the shift creates a broad posterior rectal shelf that
increases with distension of the ampulla.
 Anal ring stenosis presents with painful constipation in
infancy.
 Endocrine/metabolic
 The term “pseudo-obstruction syndrome” has been
applied to all non anatomic disorders of abnormal
peristalsis.
 Motility abnormalities may manifest with delayed
gastric emptying, small bowel stasis, and/or
constipation.
 The primary form is familial, presenting in infancy with
FTT, distension, and progressive dysmotility with
delayed gastric emptying and constipation.
Endocrine/Metabolic causes

Endocrine: Drugs:
 Hypothyroidism  Antimotility drugs
Electrolytes:  Anticholinergics
 Hypercalcemia  Antidepressants
 Hypokalemia  Opiates
 Antacids
 Phenothiazines
 Methylphenidate
Encopresis
 predominantly ~ 3 - 7 yrs
 The child is not aware of the soiling until it is
nearly complete.
 Manometry shows decreased sensitivity to
distension.
 In one study 40% experienced delays in toilet
training, and 60% reported painful stools
before age of 3 years.
 > 90% of chronic encopresis occurs in the
context of functional constipation.
Complications of constipation

 Abdominal or rectal pain and encopresis

 Enuresis >40% of children who have encopresis
 Increased frequency of urinary tract infection and
potential obstruction of the left ureter.
 .

 The dilated lower colon may lose enough tone to

allow internal prolapse or intussusception.
 Psychosocial disorders- low esteem, behavioral
disorders
Complications of constipation

 Chronic low-grade internal prolapse creates an

ischemic ulcer of the rectal wall (solitary rectal ulcer
syndrome).
 The diffuse irritation of the colon caused by firm
stool even may lead to protein-losing enteropathy.
 The social stigma associated with encopresis can be
very debilitating to any child.
Diagnostic approach History
 birth history, timing of passage of meconium.
 introduction of cow milk is the most
constipating component of the young child’s
diet
 Transitions-child care, all-day school, toilet
training
 Family Hx- aganglionosis, cystic fibrosis,
hypothyroidism, neurofibromatosis, or
myopathies
History (cont.)
 The character of the stools- for consistency,
caliber, volume, and frequency.
 The age and circumstances at onset.
 A history of possible sexual or rectal abuse
should be elicited
 prior surgery
 neonatal complications (NEC)
 Drugs-
Physical examination

 Documentation of growth and weight gain

 Signs of systemic diseases include a thorough
neurologic evaluation.
 The abdomen is examined for degree of distension
Bowel sounds are documented,
 perineum is inspected for evidence of encopresis,
streptococcal infection, fissures, and trauma (abuse)
 The anal opening is observed, watch for perirectal
manifestations of Crohn‘s disease
Physical examination (cont.)

 A dilated ampulla filled with retained firm

stool is a feature of functional retention.
 The abdominal examination may
demonstrate palpable dilated loops of
sigmoid and distal colon.
 The back should be examined for sacral skin
clues to lower spine deformity.
 Tendon reflexes should also be assessed to
rule out neurological problem.
Laboratory investigations

 Thyroid functions
 Serum calcium, magnesium, UEC
 Urine mcs
 The plain abdominal Xray may be of value.
 Lumbosacral spine radiographs or magnetic
resonance imaging if indicated.
 Lab…

 The contrast enema defecogram -assessing pelvic

muscle function following surgery or in the context of
central nervous system disease.
 Anorectal manometry - to evaluate internal anal
sphincter relaxation and determine the level of pressure
awareness in older children.
 It also will identify the 25% of chronically constipated
children who exhibit a paradoxic increase in external
anal sphincter pressure.
 Laboratory investigations
(cont.)
 Total colonic motility- evaluation of
neuropathic or muscular dysmotility in
chronic intestinal pseudo-obstruction.
 Suction rectal biopsy -stain the tissue for both
ganglion cells & acetylcholinesterase.
 The rectal biopsy - amyloidosis, graft versus
host disease, lipid storage disease, or Crohn
disease.
Plain Abdominal Xrays

Plain abdominal radiograph that

demonstrates stool throughout the colon.
 Approach to constipation(infants)
History & physical examination Delayed passage
Of meconium
yes
No
Hirschsprung Rectal bx Functional constipation
disease Manometry

Disimpaction yes
Fecal impaction
Maintenance Rx No
Not effective
Maintenance Rx
Not effective Diet,laxative,toilet training
Re-assessment
Re-educate Effective
Diff.medication
Wean and observe
Not effective

Blood tests:
T4,TSH,Ca,Celiac serology
 Approach to constipation(> 1
History
Yr) and physical examination Functional constipation
Yes
Disimpaction Fecal impaction
Maintenance Rx No

Not effective Maintenance Rx

Diet,laxative,toilet training
Re-assessment Effective
Re-educate
Diff.medication Wean and observe

Not effective

Blood tests:
T4,TSH,Ca,Pb,Celiac serology
Management: recommendations for children
Disimpaction: oral or rectal medication,or enemas
Diet: a balanced diet,containing whole grains, fruits,
vegetables
Laxative:lactulose,sorbitol,magnesium hydroxide,
mineral oil are safe & effective
Behavioral therapy:toilet training (5-10min after meal)
Rescue therapy:short course of stimulant laxative