Constipation

A 6 year old boy is brought to the office with the chief complaint of being constipated. He was toilet trained without difficulty at 3 years of age and has had no problems with urination. He has been gaining weight and growing well. How would you evaluate this patient?

Constipation

  1. Definition is: hard stools, difficult defecation, or frequency of defecation less than three times in a week for more than one month.
  2. The average 4 year old has 1.2 stools per day
  3. Encopresis is defined as soiling in the presence of functional constipation

Significance

1.     Association with emotional and behavioral problems (cause and effect may go in either direction: evaluate each case)

2.     Poor oral intake/nutrition may lead to below average weight, height and BMI in patients with constipation as the primary problem.   They and their parents may also experience increased levels of stress.

3.     In those with emotional/behavioral problems leading to constipation, many patients are overweight.  Overweight children with chronic constipation are more resistant to treatment than their normal weight counterparts, so treatment should be more diligent.

Differential Diagnosis

  1. Functional or voluntarily withholding of stools leading to soiling (encopresis)
  2. Hirschsprung's Disease- aganglionosis
  3. Anal stenosis or anal strictures
  4. Anteriorly placed anal opening
  5. Obstruction of the gastrointestinal tract
  6. Hypothyroid disease
  7. Hypokalemia 
  8. Hypercalcemia
  9. Neuromuscular and spinal cord diseases
  10. Drugs
    1. narcotics
    2. vincristine
    3. antacids
  11. excessive milk in diet, poor fluid intake, lack of bulk in diet
  12. Cow’s milk intolerance
  13. Botulism

Important questions to ask in your history

  1. How often does the child have a bowel movement? 
  2. What is the consistency of the stool?
  3. Is there pain when he goes to the bathroom?
  4. Does he have associated abdominal pain?
  5. Are the stools so large that they are unflushable and need to be chopped up?
  6. Is there blood in the stools?  Surrounding the stools?  Are the stools black?
  7. When and how have the bowel habits changed?
  8. Does he sit on the toilet? 
  9. What is his diet?
  10. Age when potty trained

Physical findings that may be helpful

  1. Abdominal exam palpating for masses or hard stool
  2. Rectal exam. In Hirschsprung's disease the ampulla will be empty and in encopresis the ampulla is often full of stool. 
  3. Anal inspection for fissures that can cause painful stools 
  4. Reflexes and strength in the lower extremities
  5. Inspection of the underwear for soiling
  6. Growth and Development

Treatment

  1. If you suspect Hirschsprung's disease, need surgical consult for biopsy 
  2. Diet manipulation with plenty of fiber and fluids
  3. Stool softeners and gentle laxatives may be helpful. In infants, dark Karo syrup, prune juice or pear juice may be tried. Also, Maltsupex may be helpful
  4. If you suspect encopresis, discussing the problem with the parents and child is important. The child should be instructed to sit on the toilet for 10 minutes after all meals. The goal is not to have a bowel movement at first, but to learn to sit on the potty. The child should be started on mineral oil at night to lubricate the lower intestinal tract and decrease the pain associated with passing stool. This will also make it more difficult for the child to "hold back". Laxatives may also be tried. In some instances, enemas may be necessary to empty out the colon. Lots of encouragement to the child and the family is important and follow-up should be arranged in 1-2 weeks.

References

  1. Abi-Hanna A and Lake AM. Constipation and Encopresis in Childhood. Pediatrics in Review. 1998; 19:23-31.
  2. Loening-Baucke, V. Encopresis and Soiling. Pediatric Clinics of North America. February 1996.
  3. Nolan, T. and Oberklaid, F. New Concepts in the Management of Encopresis. Pediatrics in Review. Volume 14; 11 November 1993.
  4. Worman, S and Ganiats, T. Hirschsprung's Disease: A Cause of Chronic Constipation in Children. American Family Physician. Feb., 1995.
  5. Vera Loening-Baucke, Erasmo Miele, and Annamaria Staiano Fiber (Glucomannan) Is Beneficial in the Treatment of Childhood Constipation. Pediatrics, Mar 2004; 113: e259 - 264. 
  6. AI Bell, and MI Levine The psychologic aspects of pediatric practice; I. causes and treatment of chronic constipation Pediatrics 14: 259-266.
  7. H. L. Nancy Kim, Kenneth W. Gow, Janice G. Penner, Geoffrey K. Blair, James J. Murphy, and Eric M. Webber Presentation of Low Anorectal Malformations Beyond the Neonatal Period Pediatrics 105: e68.
  8. Orvar Swenson Hirschsprung’s Disease: A Review Pediatrics 109: 914-918
  9. A Schonwald, L Rappaport. Encopresis. Pediatrics in Review August 2004
  10. Borowitz S et.al. Treatment of Childhood Constipation by Primary Care Physicians: Efficacy and Predictors of Outcome. Pediatrics April 2005
  11. Loening-Baucke V and Pashankar D. A Randomized, Prospective, Comparison Study of Polyethylene Glycol 3350 Without Electrolytes and Milk of Magnesia for Children with Constipation and Fecal Incontinence.  Pediatrics August 2006
  12. vanJijk et al. Behavioral Therapy for Childhood Constipation.  Pediatrics May 2008
  13. Chao HC, et al. Constipation and Growth: Something New to Consider. Pediatric Research. 2008;64(3):308-311
  14. Misra S, Lee A, Gensel K. Chronic Constipation in Overweight Children. JPEN J Parenter Enteral Nutr MARCH-APRIL 2006 vol. 30 no. 2 81-84