When The Going Gets Tough Diagnosis and Treatment

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When The Going Gets Tough. Diagnosis and Treatment of Constipation in Infants and Children

When The Going Gets Tough. Diagnosis and Treatment of Constipation in Infants and Children DR NIR FIREMAN PAEDIATRIC GASTROENTEROLOGIST MACMURRAY CENTRE

Outline What is functional constipation Diagnosis and investigation Laboratory? Tx Pharmacology (Disimpassion/maintenance) Nonpharmacologic Role

Outline What is functional constipation Diagnosis and investigation Laboratory? Tx Pharmacology (Disimpassion/maintenance) Nonpharmacologic Role of Anorectal Manometry

Types of constipation Primary or Functional- Most common Secondary or Organic- Red Flags

Types of constipation Primary or Functional- Most common Secondary or Organic- Red Flags

Diagnostic Criteria - Children ROME IV (Gastroenterology 2016; 150: 1456– 1468) Developmental age >4

Diagnostic Criteria - Children ROME IV (Gastroenterology 2016; 150: 1456– 1468) Developmental age >4 years 2 or more of the following Less than 2 defecations per week At least 1 faecal incontinence per week History of withholding and/or retentive posturing History of painful or hard bowel movements Presence of a large fecal mass in the rectum History of large diameter stools that can obstruct the toilet

Diagnostic Criteria- Infants and Toddlers ROME IV (Gastroenterology 2016; 150: 1443– 1455) Developmental age

Diagnostic Criteria- Infants and Toddlers ROME IV (Gastroenterology 2016; 150: 1443– 1455) Developmental age <4 years 2 or more of the following Less than 2 defecations per week History of excessive stool retention History of painful or hard bowel movements History of large-diameter stools Presence of a large faecal mass in the rectum

Diagnostic Criteria- Infants and Toddlers Infant Dyschezia Not constipation Infant <9 months of age

Diagnostic Criteria- Infants and Toddlers Infant Dyschezia Not constipation Infant <9 months of age Reassurance. No need for treatment

Diagnosis - Back to Practice � Diagnosis Careful history Physical Examination- To finger or

Diagnosis - Back to Practice � Diagnosis Careful history Physical Examination- To finger or not to finger? Red Flags? Abdominal X-ray?

Treatment � Education � Medication � Behavioral modification � Close follow up

Treatment � Education � Medication � Behavioral modification � Close follow up

Physiology of Defecation 1. Stool stretch the rectum and stimulate stretch receptors 2. A

Physiology of Defecation 1. Stool stretch the rectum and stimulate stretch receptors 2. A spinal cord reflex stimulate contraction of the rectum 3. The spinal cord reflex also relax the internal sphincter 4. Voluntary relaxation or contraction of the external sphincter

Constipation Cycle Soiling Rectal wall stretch Painful bowel movement Increase in size and consistency

Constipation Cycle Soiling Rectal wall stretch Painful bowel movement Increase in size and consistency of the stool Voluntary withholding Prolonged faecal stasis

Treatment- Education � Reassurance- No organic cause � Constipation is a chronic condition �

Treatment- Education � Reassurance- No organic cause � Constipation is a chronic condition � Not a quick fix -Need for medication and behavioral modification for long time � “The poop in you” video on You. Tube � https: //www. youtube. com/watch? v=Sg. Bj 7 Mc_4 sc

Treatment - Medication � Act fast, hit hard � Determine impaction � Laxatives Lubricant-

Treatment - Medication � Act fast, hit hard � Determine impaction � Laxatives Lubricant- Mineral oil Stool Softener- Sodium Docusate (Coloxyl) Osmotic- PEG (Molaxole), Lactulose, Mg. OH Stimulant- Senna, Bisacodyl, Pico sulfate � Avoid regular PR medications

Treatment - Medication Disimpaction PEG 1 -1. 5 gr/kg Enema/Suppository ? � Maintenance –

Treatment - Medication Disimpaction PEG 1 -1. 5 gr/kg Enema/Suppository ? � Maintenance – Lactulose 1 -3 ml/kg Molaxole 0. 5 -1 gr/kg Treatment for at least 2 month, with 1 month being symptoms free

Treatment- Role of Diet � Maintain normal diet � Prunes, Kiwifruits � Add fiber

Treatment- Role of Diet � Maintain normal diet � Prunes, Kiwifruits � Add fiber to bulk up but not as a treatment � Probiotics?

Behavioral modification � Regular Medication � Regular physical activity � No withholding � Toilet

Behavioral modification � Regular Medication � Regular physical activity � No withholding � Toilet routine – Gastro-colonic response � Proper sitting – Use a step � Close follow up

Other investigation � Lab- Coeliac, Thyroid, Ca � Allergy? � Colonic transit time �

Other investigation � Lab- Coeliac, Thyroid, Ca � Allergy? � Colonic transit time � Nuclear study � MRI � Anorectal Manometry

Colonic Transit Time Normal Outlet obstruction Slow Transit

Colonic Transit Time Normal Outlet obstruction Slow Transit

Scintigraphy Slow Transit Time Outlet Obstruction Normal

Scintigraphy Slow Transit Time Outlet Obstruction Normal

Anorectal Manometry � Recto Anal Inhibitory Reflex (RAIR) to exclude Hirschsprung's disease and anal

Anorectal Manometry � Recto Anal Inhibitory Reflex (RAIR) to exclude Hirschsprung's disease and anal achalasia � Squeeze test � Bear Down- Dysenergic defecation � Sensation- First Urge, Maximal tolerance

Take Home Message Constipation is very common Recognize and treat early Soiling is most

Take Home Message Constipation is very common Recognize and treat early Soiling is most common secondary to constipation Behavioral modification is part of the treatment Close follow up and treatment optimization