Constipation

Question 1

What is the main cause of constipation in children?

Answer 1

Most cases are idiopathic/functional constipation (90-95%)

Question 2

What secondary causes of constipation are there? (8)

Answer 2

• hirschsprung’s disease
• cystic fibrosis (esp. if meconium ileus)
• hypothyroidism
• spinal cord lesions
• sexual abuse
• intestinal obstruction
• anal stenosis
• cows milk intolerance

Question 3

What lifestyle factors can cause constipation?

Answer 3

• low-fibre diet
• poor fluid intake
• sedentary lifestyle
• psychosocial problems (difficult home or school environment)

Question 4

Define encopresis

Answer 4

Soiling of underwear with stool in children who are past the age of toilet training (>4yo)

Question 5

What usually causes encopresis?

Answer 5

Constipation with overflow

Question 6

How is encopresis managed? (4)

Answer 6

• If constipated → laxatives
• Reassure, address stress and review toilet training
• Pelvic floor exercises
• Star charts

Question 7

What are the clinical features of constipation? (7)

Answer 7

• <3 stools per week
• Hard stools that are difficult to pass
• Rabbit dropping stools
• Straining and painful passage of stools
• Abdominal pain
• Abnormal posture → retentive posturing
• Faecal impactation causing overflow diarrhoea

Question 8

What are the red flags of constipation to refer with? (5)

Answer 8

• Failure to pass meconium in first 24 hours
• Failure to thrive
• Abdo distension
• Lower limb weakness/numbness
• Ribbon stool pattern (anal stenosis)

Question 9

What would a ballotable mass indicate?

Answer 9

Kidney mass rather than faecal impactation - still need urgent referral

Question 10

What investigations are used to explore constipation?

Answer 10

X ray showing stool in the rectum

Question 11

What are the main 2 principles of management for constipation?

Answer 11

1. Dietary & lifestyle modification
   [NICE says don’t use dietary interventions alone as 1st line]
   - Fluid and fibre intake (drink more water + eat more fruit & veg)
   - Exercise more
2. Behavioural interventions:
   - Scheduled toileting
   - Reward system

Question 12

What do we do for management if faecal impactation present?

Answer 12

Recommend disimpactation regimen:
- Osmotic laxative (movicol - polyethylene glycol + electrolytes) → escalating dose over 2 weeks
- if no improvement: add senna (stimulant laxative)

Question 13

What do we do for management if no faecal impactation?

Answer 13

Osmotic laxative (movicol) and reduce dose gradually once normal bowel routine established

Question 14

When do we need urgent referral for AXR?

Answer 14

If systematically unwell or signs of bowel obstruction

Question 15

Complications of paediatric constipation? (6)

Answer 15

• pain
• reduced sensation
• anal fissures
• haemorrhoids
• overflow and soiling
• psychosocial morbidity

Question 16

How does abdominal migraine present? (4)

Answer 16

• Non-specific, generalised abdominal pain
• headaches
• nausea
• PMH or FH of migraines