What is encopresis?
What is primary & secondary encopresis?
repetitive in/voluntary passage of stool in the underwear or inappropriate places after an age when s/he should be toilet trained (4yo); at least 1/mo for at least 2 mo prior to dc. Primary (continuous) never tt. Secondary (discontinuous) previously tt but begin to soil
What is constipation?
acute or chronic condition is when stool is retained, hard, infrequent and can become impacted in the colon
What are the two subtypes of encopresis?
- encopresis with constipation (functional retentive fecal incontinence) a/w stool retention, constipation, and incontinence overflow
- encopresis without constipation (functional non-retentive fecal incontinence)-less common. WNL exam and studies
ROME IV Criteria for functional constipation in infants & children
> =2 occurring at least 1/wk. for minimum 1mo
- <=2 defecations in toilet/week w/developmental age of at least 4
- @ least 1 episode of fecal incontinence/wk
- Hx of retentive posturing or excessive volitional stool retention
- Hx of painful or hard BMs
- presence of lg fecal mass in rectum
- Hx of lg diameter stools that can clog toilet
- After appropriate eval, symptoms can’t be fully explained by another medical condition.
Describe children with encopresis with constipation.
often have hx of an acute stool problem that was not adequately managed-cycle of constipation, painful defecation, stool retention, more painful defecation….leads to Distention of the colon and stretching of the rectum ineffective peristalsis, decreased sensory threshold in the rectum and weekend rectal in sphincter muscles. Soft, semi formed, or liquid stool from higher in the colon leaks around the retained stool and passes uncontrollably through the rectum. The child is almost always unaware of actual incontinence. They may either refuse or be willing to use the toilet.
describe the physiologic factors related to encopresis with Constipation
- inadequate fluid intake
- dehydration caused by illness and fever or during active play in hot weather
- A change in diet, such as the introduction of solids or increased Khyber hydrates;
Secondary stool retention and Constipation due to: - Painful bowel movements
- Anal fissures
- Paradoxic constriction of the external anal sphincter muscle during attempted defecation
- Neurogenic conditions ( ie aganglionic colon (HD), cerebral palsy, myelomeningocele)
- Endocrine and metabolic conditions (hypothyroidism)
- Medication (opioids, iron supplements, anticholinergics)
History with encopresis with constipation: early detection and treatment are important. What specific questions should be asked?
- Does s/he complain of abdominal pain, bloating, loss of appetite?
- How often is there a BM?
- Are there situations when he refuses to defecate or urinate?
- Describe the process. Is it painful? Resistance? Using toilet?
- What is the quality of the stool?
- Describe issues with hygiene.
- Does a child have enuresis? History of UTI’s?
RED Flags for Constipation
- Constipation starting extremely early in life (< 1 mo)
- Passage of meconium >48 hours
- Family history of Hirschsprung Disease (HD)
- Ribbon stools
- Blood in stools in the absence of anal fissures
- Failure to thrive
- Fever
- Bilious vomiting
- Abnormal thyroid function
- Severe abdominal distention
- Decreased lower extremity strength/tone/reflex
- Perianal fistula
- Abnormal position of anus
- Absent ana lor cremasteric reflex
- Tuft of hair on spine
- Sacral dimple
- Gluteal cleft deviation
- Extreme resistance or fear during annual inspection
- Anal scars
What should be included on the physical exam for constipation?
- overflow soiling
- Abdominal distention
- Abdominal tenderness on palpation
- Mass felt at the middle of the suprapubic area (descending:)
- Anal fissures
- Sacral dimple or hair tuft
- Neurologic signs: absent or diminished abdominal, cremasteric, anal wink reflexes, and deep tendon reflexes in lower extremities.
What are diagnostic studies for encopresis with Constipation?
No X rays or laboratory tests are recommended unless there are alarming signs that indicate an underlying condition for Constipation.
However, and abdominal flat plate can be indicated with fecal impaction is suspected, abdominal exam cannot be performed or unreliable. The abdominal film can show accumulation of stool in the sigmoid:
What are the differential diagnosis for encopresis with Constipation?
*Anal rectal stenosis *spina bifida occulta *spinal cord dysplasia
*HD *mental retardation *hypothyroidism
*hyperkalemia *CP *CF.
The infant exhibiting normal red-faced grunting and straining with defecation is not constipated
What are the acute treatment approaches for encopresis with Constipation?
- Bowel evacuation using polyethylene glycol (PEG) solution are as effective as enemas and less traumatizing
- Bowel retraining to establish a regular pattern of stooling
- Ongoing maintenance with medication as needed, normal physical activity, regular toileting hygiene to prevent recurring Constipation.
- Education with a clear message that the dynamics of encopresis (retention, colon stretching, decreased peristalsis, impaction, leaking end) they are not voluntary and can be reversed with hard work.
- PG is the first line therapy for children with functional Constipation and or fecal impaction, although it is not FDA approved for use in children.
- Lactulose are recommended only if peg is not available.
What is the maintenance treatment approaches for encopresis with Constipation?
- For maintenance PEG is recommended as first line therapy, although lactulose can be given if not available.
- Second line treatment MOM, mineral oil, and stimulant laxatives. Enemas are not recommended for maintenance therapy.
- Maintenance medications need to be continued for a minimum of 2 months and should not be stopped until 1 month after resolution of the problem. Medications should be decreased gradually and if any problems recur, adjusted back up to the last successful dose and given 2 additional weeks before attempting to decrease again.
What are complications of and compressive Constipation?
- Social, interpersonal, and family relations are at grave risk.
- Intractable Constipation, and even megacolon, can be seen in children with Down syndrome, CP, or neurologic conditions.
What is toilet refusal syndrome (TRS)?
Pattern of successfully using the toilet to urinate, but refusal to use the toilet for bowel movements. Encopresis without Constipation also fits this description.
Who experiences TRS?
Many young healthy children experiences for short period of time. Presence of younger siblings in the household and parents inability to set limits for the child may be related. Constipation and painful BMs appear to precede rather than follow the problem period
History with TRS:
- Bladder control but refusal to defecate in toilet
- A regular or irregular pattern of bowel movements
- Consistent signs that a bowel movement is imminent
- May have a history of hiding when defecating, either before or after toilet training begins.
What are the differential diagnosis for TRS?
Stool withholding, Constipation, and encopresis.
What is the treatment for TRS?
- Return the child to diapers and re induce toilet training in about a month or when child indicates interest. This pattern may continue for several weeks or months.
- For older children schedule a daily time for them to sit on the toilet 5 to 10 minutes when they typically have a BM. These times should be positive, never punitive or forced. Excessive praise is not recommended, because the child is simply doing what is expected.
What are complications of TRS?
Stool withholding, Constipation, and impaction.. Psychological complications as well.
Table
Management of children with mild encopresis without Constipation?
• monitor diet
• Recommended water intake is about 1 ounce\ KG\ D
• Ensure adequate fiber and water intake for age:
o 4 to 8: 25 milligrams grams/ D
o 9 to 13 girls: 26G/ D
o 9 to 13 boys: 31 G/ D
o 14 to 18 girls:26 G/ D
o 14 to 18 boys: 38G/ D
• Legumes, vegetables, and some fruits are good sources of fiber.
• Decrease milk to 16 ounces/ D
• Do not allow excessive dairy, rice, appl sauce, bananas, white flour, or potatoes.
• Give child all responsibility of own toilet habits. Stop parental reminders to use toilet. Stop all encouragement and criticisms.
• Establish regular toileting routine
• Avoid use of stool softeners or laxatives
• Encourage daily physical activity
• May use incentives or rewards to reinforce positive behavior. Have parent and child agree on reward beforehand so that it can be discussed as a positive, subtle reminder.
What is acute diarrhea?
Disruption of the normal intestinal net absorptive versus secretory mechanisms of fluids and electrolytes, resulting in excessive loss of fluid into the intestinal lumen.
Which can lead to dehydration, electrolyte imbalance, and in severe cases, death in those also malnourished.
<2 yo = daily stool volume greater than 10 ML/ KG.
>2 yo = >4/24 hours
Duration can last up to 14 days
How do viruses cause acute diarrhea?
They can injure the absorptive surface of mature villus cells, which reduces the amount of fluid absorbed. Some can release viral enterotoxin (i.e. rotavirus). The loss of water and electrolytes ensues and there can be volumes of watery diarrhea, even if the child is not being fed.
How do bacteria and parasites cause acute diarrhea
Can adhere &/or translocate, causing non inflammatory diarrhea. Bacteria can also damage the anatomy and functional ability of the intestinal mucosa by direct invasion. Some bacteria release endotoxins, whereas others release cytotoxins that can result in the excretion of fluid, protein, and cells into the intestinal lumen and an inflammatory response in some cases.
