Chronic Constipation

Question 1

What is constipation?

Answer 1

Infrequent passage of stool

Question 2

What do you want to know about the child presenting with constipation?

Answer 2

• How often they pass stool?
• How hard is it?
• Is it painful?
• Has there been a change?

Question 3

What is normal stool frequency?

Answer 3

4 per day to 1 per week

Question 4

What does stool frequency depend on?

Answer 4

• Age

- Diet

Question 5

What are the components of the Bristol stool chart?

Answer 5

• Type 1= separate hard lumps
• Type 4= smooth sausage like
• Type 7= entirely liquid

Question 6

What are some signs and symptoms of constipation?

Answer 6

• Poor appetite
• Irritable
• Lack of energy
• Abdominal pain or distension
• Withholding or straining
• Diarrhoea
• Urinary issues
• Pale with bags under their eye

Question 7

Why do children become constipated?

Answer 7

• Poor diet (lack of fluid, excess milk)
• Potty training or school toilets issue
• Intercurrent illness
• Medications (opiates and Gaviscon)
• Family history
• Sacred to go (psychological)
• Anatomical issues
• Hirshsprungs
• Lead poisoning
• Hypothyroidism

Question 8

What is the vicious cycle of constipation?

Answer 8

• Large hard stool
• Leads to pain and fissuring
• Child withholds stool
• Becomes constipated

Question 9

How does overflow diarrhoea develop?

Answer 9

• Child enters the vicious cycle of constipation
• Rectum tells them they need to go but the child clenches the external sphincter
• Poo continues to be dehydrates by bowel becoming harder
• Back passage begins to stretch and creates a mega rectum
• Soiling occurs when the mega rectum holds the internal sphincter open and the child is unable to clench the external sphincter

Question 10

What social treatment of constipation is there?

Answer 10

Explain treatment to parents

Dietary

• Increase fibre
• Increase fruit
• Increase vegetables
• Increase fluids
• Decrease milk

Question 11

What psychological treatment of constipation is there?

Answer 11

Reduce the aversive factors by making going to the toilet a pleasant experience

• Correct height
• Not cold
• School toilets

Avoid punitive behaviour from parents

Reward good behaviour

• General praise and star charts
• Encourage child to try going to the bathroom after every meal

Question 12

What medical treatment is there for constipation?

Answer 12

Soften stool and stimulate defecation

• Osmotic laxatives (lactulose)
• Stimulant laxatives (senna, picolax)
• Isotonic laxatives (movicol)

Question 13

What are the advantages of laxatives?

Answer 13

• Non invasive

- Given by parents

Question 14

What are the disadvantages of laxatives?

Answer 14

• Non compliance

- Side effects

Question 15

How much treatment should a child receive?

Answer 15

Enough to make them go

Question 16

How long should a child receive treatment?

Answer 16

• Until no longer required

- Related to duration of problem

Question 17

How is impaction treated?

Answer 17

• Empty impacted rectum
• Empty colon
• Maintain regular stool passage
• Slow weaning off treatment

Question 18

How can constipation be confirmed on imaging?

Answer 18

Colonic marker study

• When x-rayed at the end of the week the markers should have already be excreted.
• In constipation the markers can be seen in the rectum and distal colon

Question 19

What type of laxative is lactulose?

Answer 19

Osmotic laxative

Question 20

What type of laxatives are senna and picolax?

Answer 20

Stimulant laxatives

Question 21

What type of laxative is movicol?

Answer 21

Isotonic laxative