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Chronic Constipationand Encopresis
Vctor M. Pieiro, M.D.
Uniformed Services University
Bethesda, Maryland
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Definition and Frequency
Constipation is a symptom, not adisease
Stools are small, hard or
infrequent
3% of outpatient pediatric visits
10-25% prevalence in PediatricGI practice
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Constipation
Most common GI outpatient problemMay start at any age
Rarely due to structural abnormality or
systemic disease
Children DO NOT outgrow it
spontaneously
Prognosis is good if treated
appropriately
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Normal Bowel Habit
Pre school children
Stool frequency QOD - TID (95%)
Stool weight 25 gms
Transit time 33 hrs
Toilet training ages 2-3 yrs.
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Colonic Motility
Colon has complex motility patterns
Colonic contents moved to the cecum by
waves of "antiperistalsis"
Colonic haustrations prominent in
transverse and descending colon
Giant migrating contractions originate
in transverse colon and rapidly reachthe rectum (gastrocolic reflex)
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Mechanisms of Defecation
Inflation Reflex
Seen after age 2
Distension of rectum
Stimulus sensory nerves
Conscious awareness
Transient relaxation of external anal
sphincter (EAS)
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Mechanisms of Defecation
Rectosphincteric Relaxation Reflex
Distension of rectum
Sensory nerves (via myenteric plexus)
Inhibition of smooth muscle internal
anal sphincter
Relaxation of IAS
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hronic Idiopathic ConstipatioMale predominance 1.5:1
Age of onset 0-1 yr 25%
0-5 yr 70%
Event at onset 30%
Large stools 75%
Withholding behaviors 40%
Failed toileting 30%
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Clinical Presentation
Family history 10-50%
Rectal bleeding 25%
Enuresis/UTIs 15%
Abdominal Pain 10-50%
Psychologic problems 20%
Rectal prolapse 3%
Poor appetite 26%
Previous therapy 90%
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Clinical Presentation
Physical examination
Abdominal distention 20%
Abdominal mass 30-50%
Fecal impaction 40-50%
Weight < 5% 0-10%
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Anorectal Manometry
Proximal rectal balloon to distend the
rectum
Pressure sensors used to measure IASand EAS
Distention of rectum triggers the
Inflation and Rectosphinctericrelaxation reflexes
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Pathophysiology
I. Resting anal sphincter pressure
Increased, normal or decreased
II. Rectosphincteric relaxation reflex
Critical volume ( minimal volume of
rectal distention required to elicit the
relaxation reflex) is often increased
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Pathophysiology II
III. Rectal Sensitivity - ConsciousAwareness
Threshold volume (volume required to
produce conscious awareness) is oftenincreased
In encopresis IAS relaxation occurs at
volumes that do not stimulate
conscious awareness
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Pathophysiology III
IV. External anal sphincterParadoxical EAS contraction
(unconscious EAS contraction during
defecation) in severe constipation
V. Expulsion failure
Patients with severe constipation and
encopresis may have an inability to
defecate balloons
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Potentiation of Risk for Encopresis
Stage I Infancy and Toddler Years
Simple constipation
Congenital anorectal problems
Parental overreaction
Coercive medical interventions
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Potentiation of Risk for Encopresis
Stage II 2 to 5 years
Psychosocial stresses
Coercive or permissive training
Toilet fears
Painful or difficult defecation
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Potentiation of Risk for Encopresis
Stage III Early School Years
Avoidance of school bathrooms
Prolonged gastroenteritis
Attention deficit disorder
Frenetic life-stylesPsychosocial stress
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Differential Diagnosi
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Medical
Hypothyroidism Diabetes insipidus
Hypokalemia RTA
Hypercalcemia Botulism
Uremia CNS disorders
Depression Anorexia nervosa
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Gastrointestinal Disorders
Intestinal Pseudo-obstruction
Cystic fibrosis
Crohn's disease
Celiac disease
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Drugs and Toxins
Anticholinergics Iron
Anticonvulsants BismuthOpiates Lead
Antidepressants Barium
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Anatomic
Anorectal anomalies
Spinal cord injury
Sacrococcygeal teratoma
Hirschsprung's disease
Meningomyelocele
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Anterior Anal Displacement
Anterior ectopic anus
Anal canal + IAS anteriorly located
EAS in normal positionAnteriorly located anus
Anal canal + both sphincters anteriorly
located
A i A i
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Anterior Anal Displacement
Rectal exam
Posterior angulation of anal canal
Posterior shelfTreatment
Often conservative
Surgical repair if severe
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Hirschsprung's Disease
Congenital Aganglionosis of colon
Rectosigmoid colon 80%
Transverse/Ascending 15%Total aganglionosis 5%
Ultrashort Rare
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Hirschsprung's DiseaseBarium enema
Distal narrowed segment, transition zone,
"saw-toothed" contractions
Anorectal manometry
Lack of rectosphincteric relaxation reflex
Rectal biopsyDiagnostic (adequate specimen, expert
atholo ist
E i
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Encopresis
Weissenberg - 1926
Involuntary passage of whole bowel
movements in the underwear or on
abnormal place
Now commonly used synonymously
with fecal incontinence or soiling
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Treatment
Must explain the pathophysiology of the
problem
Improves compliance with therapy
Alleviates the guilt and blame the
parents may feel
Decreases embarrassment child isexperiencing
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Treatment
Three Stages
Education
Initial Catharsis (Whoosh)
Maintenance
C h i
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Catharsis
Day 1 Magnesium citrate 5-10 oz. P.O.
Days 1-3 Mineral oil enema 3-4 oz. PR
Days 1-3 Fleet enema 2-4 oz. PR
Days 2-4 Dulcolax 5-10 mg. P.O. QD
M i t R i
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Maintenance Regimen
High Fiber Diet
MOM 0.5-1 ml/kg/dose BID
Mineral oil 0.5-1 ml/kg/dose BID
Behavior modification (Toilet training)
Follow up visits every month
A l P i i I d
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Anal Position Index
Ratio of anus-fourchette distance tococcyx-fourchette distance (scrotum in
males)
BA
Normal Ratios A/B
> 0.34 in females
> 0.46 in males
{
}
Di ti E l ti
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Diagnostic Evaluation
Complete History and PhysicalExamination
Laboratory Studies
CBC, ESR, U/A, Urine culture
Stool culture, O & P, occult blood
Serum glucose, calcium, phosphorusThyroid function studies
Diagnostic Evaluation
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Diagnostic Evaluation
Radiographic Studies
Abdominal plain film, BE
Special diagnostic Studies
Rectal suction biopsy
Anorectal manometry
Indicated Studies
UGI/small bowel series
Proctosigmoidoscopy, colonoscopy
Pelvic MRI
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