Constipation and Abdominal

pain
Prepared Dr Dost Mohammad Sahar
 CONSTIPATION
Constipation is defined as a delay or difficulty in defecation,
present for 2 or more weeks and sufficient to cause significant
distress to the patient.
The normal stool frequency
decreases from 4 or more per day during infancy
to once per day at 4 yr of age.
A stool frequency of <2/week is considered abnormal for all ages.
CONSTIPATION…………..
Constipation can be divided into two groups:
functional or organic.
In a study of 135 Indian children with constipation, 85% had
functional constipation
and 15% had an organic etiology (most commonly, Hirschsprung
disease, cerebral palsy and meningom yelocele).
CONSTIPATION…………..
Approach
A detailed history and physical examination is the most useful tool for
making a diagnosis of constipation.
I. The details about pattern of stooling,
II. time of first passage of meconium,
III. presence of blood in stools, diet,
IV. stressful life events,
V. drug intake and previous surgeries should be known.
VI. A predominantly liquid and low fiber diet (milk based) is common
and contributes to constipation.
VII. A complete physical and neurological examination is essential.
CONSTIPATION…………..
Examination
for features of spina bifida (pigmentation or tuft of hair on lower
back),
power in lower limbs,
perianal sensation,
voluntary contraction and tone of anal sphincter and amount and
consistency of stool in rectum on per rectal examination are
extremely useful for diagnosis..
CONSTIPATION…………..
Presence of 'red flags‘
I. like failure to thrive,
II. blood in stools,
III. recurrent fever with loose stools (enterocohhs),
IV. recurrent vomiting,
V. lump in abdomen,
CONSTIPATION…………..
Functional Constipation
The increase in intake of low residue diet and sedentary lifestyle is responsible for
the increase in functional constipation in children. Functional constipation is defined of
presence of at least 2 or more of the followmg cntena:
(i) two or fewer defecations in the toilet per week;
(ii) at least 1 episode of fecal incontinence per week;
(iii) history of retentive posturing or excessive volitional stool retention;
(iv)history of painful or hard bowel movements;
(v) presence of a large fecal mass in the rectum; and
(vi) history of passage oflarge diameter stools that may obstruct the toilet.
CONSTIPATION…………..
Often an acute illness,
changes in diet,
coercive toilet training or non availability of clean toilet leads to
non passage of stools.
 CONSTIPATION…………..

Children with functional constipation

a. often have abdominal pain (10-70% ),
b. anorexia (10-25%),
c. enuresis or urinary tract infections (30%)
d. and psychological problems (20%).
 MANAGEMENT
No investigations are required for diagnosis in the majority of
children with functional constipation.
However, an X-ray abdomen may be done to document impaction
in select situations, e.g. an obese child who is not willing for a per
rectal examination.
Two main steps in the management are disimpaction and
maintenance therapy.
MANAGEMENT
Disimpaction
is required in patients who have a rectal impaction, i.e. presence
of a large hard mass of feces on per rectal examination.
Total bowel wash is done to clean the entire colon using
polyethylene glycol (PEG) in a dose of 1.5 g/kg/ day for 3-4
days at home.
MANAGEMENT………
Disimpaction………………
Alternatively, PEG electrolyte solution can be given in the dose of
15-40 ml/kg/hr till the rectal output is clear and devoid of solid
fecal material.
In young children, this should be done using a nasogastric tube
and in hospital under supervision.
The child should be fasting for PEG administration.
Intravenous fluids may be required in small children during this
period to maintain adequate hydration.
CONSTIPATION…………..
An alternative to oral administration of PEG is the use of phosphate enema or
sodium dioctylsulfosuccinate enema, 30-60 ml/10 kg body weight to a
maximum of 120 ml, once or twice daily for 1-2 days.
Repeated rectal enemas should be avoided in children
MANAGEMENT………
The aim of the maintenance phase is to promote regular stooling
and prevent reimpaction.
Success of this therapy is defined as passage of 1-2 soft stools
per day and no soiling.
It includes the following components:
i. Behavioral training
ii. Dietary changes.
iii. Medication
MANAGEMENT………
i. Behavioral training
involves establishing a positive routine of sitting on toilet for
passing stools after meals regularly (2-3 times per day for 5-10
min) and documenting all stool passage.
Embarrassment or punishment should be avoided.
MANAGEMENT………
ii. Dietary changes.
A nutritious diet with fruit/vegetables and adequate fluids is given.
A short trial of milk and milk product free diet may be done in
cases suspected to have milk allergy.
 MANAGEMENT………
iii. Medication.
Regular and tailor-made (as per response) laxative use is the key to success
and this should be explained to the family.
i. Osmotic laxatives like lactulose (1-3 ml/kg/day) the first line agents.
ii. Stimulant laxatives like senna or bisacodyl are to be used only
intermittently as a rescue therapy to avoid impaction.
iii. Prokinetics like cisapride are not recommended.
iv. In infants, mineral oil and stimulant laxatives should not be used.
v. Glycerin suppository is preferred over enema for impaction in infants.
 PROGNOSIS
Most of the children need maintenance therapy for 6-24 months.
About 50-60% patients achieve success at 1 yr and 70-80% in the
longterm.
Nearly 50% patients will have a relapse after successful therapy.
In nearly one third patients, constipation persists even after
puberty.
 ABDOMINAL PAIN
Abdominal pain is a common manifestation of multiple pathologies
which vary from benign to life-threatening conditions.
The pain may be acute or chronic in nature. To be able to arrive at
a diagnosis, careful history and examination and appropriate
investigations are necessary.
An understanding of pain perception in the abdomen and location
of pain provides valuable information.
The gut is innervated by the enteric nervous system which is
involved in regulating secretion, motility and in sensory perception
of visceral pain.
ABDOMINAL PAIN ……….
The enteric nervous system is also influenced by the central nervous system.
Stretching of the visceral peritoneum overlying or inflammation results in pain
sensation.
The pain from the stomach and proximal intestine is sensed in the epigastrium;
from the midgut to the periumbilical area;
and from the transverse colon to the suprapubic area.
The inflammation in the parietal peritoneum causes pain in the overlying abdominal
wall.
Thus, the pain of appendicitis is referred to the periumbilical area when the
inflammation is restricted to the visceral peritoneum, but is perceived in the right iliac
fossa when the inflammatory fluid comes in contact with the parietal peritoneum.
ABDOMINAL PAIN ……….
Pain arising from retroperitoneal structures is referred to the back
as it is sensed by the somatic nerves in the posterior abdominal
wall.
Referred pain is common in abdominal pathologies; a
subdiaphragmatic collection on the right side may manifest as
right shoulder pain
and ureteric pain is referred to the corresponding side as
testicular pain.
Radiation of pancreatic pain to the back and ureteric pain from
loin to groin are also known.
 DIAGNOSIS
Information obtained from the history and examination that aid
in the diagnosis include
I. The age of the patient
II. Duration, type and frequency of pain
III. Any nocturnal episodes
IV. Association with eating or defecation, vomiting, blood in stools,
diarrhea, constipation or obstipation, fever, joint pain, dysuria,
hematuria, weight loss, jaundice, abdominal distension, fever
and history of drug intake.
DIAGNOSIS ………….
Other systemic findings are also important as abdominal pain may
be a manifestation of metabolic conditions like diabetic
ketoacidosis.
Lower lobe pneumonia has been reported to account for 2.5-5%
of abdominal pain.
Physicians must distinguish abdominal pain due to emergent
diagnoses like appendicitis or intussusception from benign
conditions like gastroenteritis or constipation.
DIAGNOSIS ………….
Examination should be meticulous including examination of
genitalia as torsion of testes or incarcerated hernia can be easily
overlooked.
The accuracy of abdominal examination may be improved by
distracting a child with toys or engaging in conversation.
In infants and young children the manifestation of pain may initially
be as incessant cry.
Differential diagnosis should be considered in terms of age as
many diagnoses are seen more commonly in children of certain
age groups as shown in Table 11.5.
 MANAGEMENT
The management of these acute conditions includes initial stabilization of the
patient followed by specific management which may or may not be surgical.
Some of these acute conditions are described briefly:
Acute Appendicitis
Intussception
Gallstones (Cholelithiasis)
Choledochal Cyst
Malrotation
Peptic Ulcer