Learning Objectives Epidemiology - … Objectives ... • Barium enemaBarium enema ... Microsoft PowerPoint - Siddiqui handout w objectives,disclosure.ppt [Compatibility Mode]

Pediatrics Grand Rounds22 November 2013

University of Texas Health Science Center at San Antonio

1

Approaching Childhood

ConstipationpAnees Siddiqui, MD

Pediatric Gastroenterology

‘Specially for ChildrenDell Children’s Medical Center of Central Texas

Disclosure

Anees Siddiqui, MD, has no relationships with commercial companies to disclose.

Learning ObjectivesAt the end of this presentation the participant will be able to:

1. Institute an appropriate workup to differentiate functional constipation anddifferentiate functional constipation and other organic etiologies of disease

2. Understand the appropriate management options for pediatric constipation

3. Have a sense as to when referral to subspecialty care is appropriate.

Epidemiology

• Prevalence estimated up to between 0.7 to 29.6%

• Independent of age, sex, race, geography, and socioeconomic status

Epidemiology

• 3% of all visits to pediatricians

• 25% of all visits to pediatric GI

• Estimated burden to health care system of $3.9 billion / year



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Case I (M L )Case I (M.L.)

Case I (M.L.)• 2 yo with constipation since infancy

• Worsened when began walking

• N i i d il l t h• Now requiring daily ex-lax to have a weekly bowel movement

• Demonstrates witholding behavior

• Social History: Mom recollects holding the child down to force her to have a BM

Case I (M.L.)

• Started on a laxative cleanout regimen followed by maintenance

• Enforced Non-Punative

• Seen in clinic for 1 month follow up

• Complete Resolution of Symptoms

Case 2 (L R )Case 2 (L.R.)

Case 2 (L.R.)• CC: constipation not responding to medical

therapy

• HPI

• 4 yo girl with constipation since infancy

• Never toilet trained

• BM every other week

• Now with severe abdominal distension

• ROS: FTT



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Physical Examination

• General: thin NAD, distressed on examination

• Lungs: CTA B

• CV: RRR no murmer

• Abdomen: significant distension, tympanic, no masses, no HS megaly

Labs

• Normal CBC

• Normal LFTs

• Normal Chem 20

• Neg celiac, Neg thyroid, Neg Sweat

Meds

• Mirilax 17gm BID for several months

• Dulcolax 5mg BID for several weeks

• Senna 2 tsp BID for several months

• Mineral oil 1 tsp BID for several weeks

Work up• Due to severity of symptoms child is

admitted for further work up and management

• Barium enema• Barium enema

• Anorectal manometry

• Colonic monometry

• Rectal biopsy

• Lumbar MRI

Barium Enema



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Agenda

• Definitions

• Physiology / PathogenesisPhysiology / Pathogenesis

• Differential Diagnosis

• Workup

• Management

DefinitionsDefinitions

Definitions

• Constipation has multiple interpretations

• Variability of “Normal”

• 12,984 children’s parents completed questionnaires at 1, 6, 18, 30, 42 months

Paris Concensus on Childhood Constipation Teriminology

(PACCT) Group• 2 or more of the following for ≥8 weeks

• <3 bowel movement per week

• ≥1 fecal incontinence per week≥1 fecal incontinence per week

• Large stool on rectal or abdominal exam

• Stool that clogs the toilet

• Retentive Posturing or Withholding

• Painful Defecation



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PhysiologyPhysiology

Physiology

• Mechanisms of Continence

• P b t li• Puborectalis

• Internal Anal Sphincter

• External Anal Sphincter

• Anorectal Angle

Physiology

• Stool Descends to Rectum

• Passive Relaxation ofPassive Relaxation of IAS

• Stool Contacts Anal Canal

• EAS Contracts

Physiology

• OK to Poop?

• Puborectalis Relaxes

• Pelvic Floor Descends

• Anorectal Angle Straightens

• Success!!

Physiology

• Shouldn’t Poop?

• EAS and Puborectalis Contract

• Anorectal Angle Lessens

• Maintain Continence!!

Pathophysiology• Summary of Components of Defecation

• Bolus Delivery

• Bolus SensationBolus Sensation

• Pelvic Floor Reaction

• Intra Abdominal Forces

• Disruption in the above causes constipation



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Differential DiagnosisDifferential Diagnosis

Differential Diagnosis• Anatomic

• Metabolic

• Neuropathic

•• Enteric Neuropathy / Myopathy

• Abdominal Musculature

• Connective Tissue Disorder

• Drugs

• Other


• Metabolic

• Neuropathic

•• Imperforate Anus

• Enteric Neuropathy / Myopathy



• Drugs

• Other

• Anteriorly Displaced Anus

• Anal Stenosis


• Metabolic

• Neuropathic

•

• Hypothyroidism

• Hypocalcemia




• Drugs

• Other

• Hypokalemia

• Cystic Fibrosis

• Diabetes Mellitus

• Celiac Disease


• Metabolic

• Neuropathic

•• Spina Bifida




• Drugs

• Other

• Spinal Cord Trauma

• Tethered Cord

• Encephalopathy


• Metabolic

• Neuropathic

•

• Hirshsprung’s

• Non-Relaxing IAS• Enteric Neuropathy /

Myopathy



• Drugs

• Other

• Neuroectodermal Dysplasia

• Viceral Myopathy

• Viceral Neuropathy



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• Metabolic

• Neuropathic

•• Enteric Neuropathy / Myopathy



• Drugs

• Other

• Prune Belly Syndrome

• Gastroschisis


• Metabolic

• Neuropathic

•• Scleroderma




• Drugs

• Other

• SLE

• Ehlers-Danlos Syndrome


• Metabolic

• Neuropathic

•

• Opiates

• Anticholinergics• Enteric Neuropathy / Myopathy



• Drugs

• Other

• Anticholinergics

• Sympathomimetics

• Anti-Depressants (TCAs)


• Metabolic

• Neuropathic

•

• Lead Intoxication

• Vitamin D Intoxication• Enteric Neuropathy / Myopathy



• Drugs

• Other

• Vitamin D Intoxication

• Cow’s Milk Protein Intolerance

• Botulism

Differential Diagnosis

• Functional

• Celiac

• Hypothyroidism

• Calcium Derangement

• Milk Protein Intolerance

• Hirshsprung’s

Differential Diagnosis (Non Organic)

• Developmental

• Situational

• Depression

• Reduced Stool Volume



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Pathogenesis

• Some stimulus causes withholding

• Stool becomes progressively harder

• Child is more reluctant to defecate

• Colonic distension weakens peristalsis

• Constipation cycle

• Often overflow incontinence results

WorkupWorkup

Workup

• History

• Physical

History• Age of Onset

• Passage of Meconium

• Nausea / Vomiting

• Toilet Training

• Abdominal Distension

• Abdominal Pain

• Doodie Dance

• Fecal Incontinence

• Course Hair

• Fatigue

Physical Exam

• General Appearance / Vitals

• Abdomen

• Anal Inspection

• Rectal Examination

• Back Examination

• Neurologic Examination

Additonal Work-up• Imaging

• KUB ??

• Transit Studyy

• MRI of LS Spine

• Barium Enema

• Anorectal Manometry

• Colonic Motility Study

• Lab Tests



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ManagementManagement

Management

• Disimpaction

• Maintenance Therapy

• Behavioral Therapy

• Treat the Underlying Condition

Medications

• Mushers (Osmotic Laxatives)

• Pushers (Stimulant Laxatives)Pushers (Stimulant Laxatives)

• Lubricants

• Rectal

• Other

Medications

• Mushers

• Miralax (PEG)

• 1.5gm/kg/day (disempact)

• 1.0gm/kg/day (maintain)

• Milk of Magnesia (MgOH)• Pushers

• Lubricants

• Rectal

Milk of Magnesia (MgOH)

• 1 - 3cc/kg/day

• Lactulose

• 1 - 3 cc/kg/day

• MgCitrate

• 1 - 3 cc/kg/day (<6yo)

• 100 - 150 cc/day (6-12yo)

• 150 - 300 cc/day (>12yo)

Medications

• Mushers

• Senna (Ex-Lax)

• 6-11yo: 1 square QD - BID

15mg/square

• Pushers

• Lubricants

• Rectal

• >12yo: 2 square QD - BID

• Bisacodyl

• 1-3 tablets/Day (5mg)

• ½-1 suppository/Day (10mg)

Medications

• Mushers • Mineral Oil

•• Pushers

• Lubricants

• Rectal

• 15 - 30cc/yr (max 240cc) daily for disimpaction

• 1 - 3 cc/kg/day maintenance



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Medications

• Mushers• Fleets (Phosphate)

Enema• 6cc/kg up to 135cc• Pushers

• Lubricants

• Rectal

6cc/kg up to 135cc• no kids < 2 years• no more than 1/ day • Mineral Oil Enema• Glycerin Suppository

Disimpaction

• Goal is aggressive clean out

• Dealers Choice ... butDealers Choice ... but

• Miralax 17gm BID x 3 days

• Ex-Lax 1 square qDay x 3 days

• Then on maintenance

Maintenance Therapy

• Goal: 1 - 2 soft stool / day

• Expect 6 - 24 month of therapy

• Focus of Therapy

• Dietary Education

• Behavioral Modification

• Laxatives

Maintenance: Diet

• Fiber Supplementation

•Goal = (age + 5)gm/day

•Dietary: •Whole Grain Breads• Adequate Hydration

• Balanced Nutritious Diet

• ? Milk Elimination ?

•Whole Grain Breads•Cereals•Fruits Vegetables•Supplements•Benefiber•Fiber One•etc

Maintenance: Behavior

• Age Appropriate Toilet Training

• Sitting ScheduleSitting Schedule

• Incremental Rewards

• Stooling Chart

• Avoid Punitive Measures

Weaning

• Gradual tapering of medications tried every 6 monthsevery 6 months

• Stopping meds too soon is the most common cause of relapse



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Outcomes

• Rates of Successful Management Vary

• 50% - 90% success over 1 year

• Close follow up and continuation of meds is crucial

• 401 children with functional constipation (1991 - 1999)

Pediatrics. 2010 Jul;126(1):e156-62. Epub 2010 Jun 7.

• 6 - 8 weeks of intensive treatment

• Follow up at 6 months then yearly

• Standardized Questionnaire

• (Category 1) Good Outcome without Laxatives

Outcome Categories

• (Category 2) Good Outcome with Laxatives

• (Category 3) Poor Outcome without Laxatives

• (Category 4) Poor Outcome with Laxatives

Outcomes by Age

75%

Outcome by Follow-up Duration

Contributors to Poor Outcome

• Delay in ReferralDelay in Referral

• Advanced Age at Onset

• Defecation Frequency



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Take Home Points

• Definitions

• Physiology / Pathogenesis

• Significant Variability in Presentation

• Cycle of Constipation

Agenda

Physiology / Pathogenesis

• Differential Diagnosis

• Workup

• Management

• Main Dx: Functional, Milk Intolerance, Celiac, Hypothyroid, Ca

• History/Physical

• Minimum 6 months of Laxatives

Barium Enema Work up• Due to severity of symptoms child is





• Rectal biopsy

• Lumbar MRI

Work up• Due to severity of symptoms child is





• Rectal biopsy

• Lumbar MRI

Anorectal Manometry

• Balloon Simulates Fecal BolusFecal Bolus

• Attempting to ellicit the RAIR (recto-anal inhibitory reflex)



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Indications• Rule out Hirschsprung’s

• Evaluation of Intractable Constipation

• E l ti f F l I ti• Evaluation of Fecal Incontinence

• Establish candidacy for anorectal biofeedback

• Establish candiacy for anal botox injection

Hirschsprung’s Disease

Normal

HDJPGN 2006

Contrast Enema

Anorectal Manometry

Rectal Suction Biopsy

Contrast Enema

Anorectal Manometry

Rectal Suction Biopsy



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• 27 children who had > 3 biofeedback sessionssessions

• 88.9% success in treating functional constipation due to pelvic floor dysfunction

Coming SoonComing Soon...



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References• Sonnenberg A, Koch TR. Physician visits in the United States for constipation: 1958 to 1986. Dig

Dis Sci. 1989;34(4):606–611..

• Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43(3):e1–13.; ( )

• Steer CD, Emond AM, Golding J, Sandhu B. The variation in stool patterns from 1 to 42 months: a population-based observational study. Archives of Disease in Childhood. 2009;94(3):231–233.

• Bongers MEJ, van Wijk MP, Reitsma JB, Benninga MA. Long-Term Prognosis for Childhood Constipation: Clinical Outcomes in Adulthood. PEDIATRICS. 2010;126(1):e156–e162.

• de Lorijn F, Kremer LCM, Reitsma JB, Benninga MA. Diagnostic tests in Hirschsprung disease: a systematic review. J Pediatr Gastroenterol Nutr. 2006;42(5):496–505.

• Siddiqui A, Rosen R, Nurko S. Anorectal Manometry May Identify Children With Spinal Cord Lesions. J Pediatr Gastroenterol Nutr. 2011:1.

Documents

Learning Objectives Epidemiology - … Objectives ... • Barium enemaBarium enema ... Microsoft PowerPoint - Siddiqui handout w objectives,disclosure.ppt [Compatibility Mode]