Constipation

Question 1

What is constipation?

Answer 1

The infrequent or irregular passage of hard stools which leads to faecal impaction

Question 2

What is encoperesis?

Answer 2

It is the wilful soiling of the underwear with normal consistency stool
This is usually associated with psychological disturbances

Question 3

How can we classify constipation?

Answer 3

1. Acute and chronic (both including functional and organic causes)

Question 4

What is functional constipation?

Answer 4

Occurs both acutely and chronically

Usually linked to dietary, behavioral, psychogenic and ill understood malfunctions of the bowel, muscle or sphincters

Question 5

What is organic constipation?

Answer 5

There is underlying pathology including developmental anomalies, hirschsprungs diseases or anorectal anomalies
Hypothyroidism may also be a factor

Question 6

What is the Rome 4 classification of functional constipation in children under 4 years?

Answer 6

At least 2 symptoms of the below for a month in children under 4:

1. 2 or fewer defecations per week
2. History of excessive stool retention
3. History of painful or hard passage of stools
4. Presence of faceal mass in the rectum
5. History of large diameter stools
6. History of large diameter stools which can obstruct the toilet

Question 7

What is the Rome 4 classification of functional constipation in children and adolescents?

Answer 7

At least 2 more of these once a week for a month:

1. 2 or fewer defecations per week
2. One episode of fecal incontinence per week(you soil yourself)
3. History of painful or hard stools
4. Increased diameter of the stools
5. Presence of large mass in the rectum

Question 8

What is the Rome 4 classification of non-retentive faecal incontince?

Answer 8

At least 1 month history of these symptoms in children >4 years

1. Defecation in inapprplaces
2. No evidence of fecal retention
3. After physical exam, constipation cannot be explained by another

Question 9

How many children are getting contsipation?

Answer 9

10-37%

Question 10

What are the causes of organic constipation?

Answer 10

1. Hirschsprung’s disease
2. Metabolic abnormalities-hypothyroidism, hypocalcaemia
3. Prune belly syndrome
4. Anatomical malformations-the Anus is anterior
5. Cystic fibrosis, celiac disease (poor absorption)

Question 11

What are the causes of functional constipation?

Answer 11

1. Sedentary lifestyle
2. Poor eating habits
3. Rebelling against potty training
4. They don’t want to use public toilets

Question 12

What are the special investigations we can do in children with constipation?

Answer 12

1. Abdominal X-ray
2. Thyroid tests
3. Biochemistry- calcium, potassium

Question 13

What is the clinical picture of children with constipation?

Answer 13

1. Mostly boys
2. Abdominal distension
3. Abdominal pain
4. Soiling
5. Recurrent UTI’s
6. Enuresis

Question 14

What would lead us to think that the constipation is caused by a organic cause?

Answer 14

1. Explosive stool after rectal exam
2. Delayed meconium passing and abnormal stool after birth
3. Abnormalities in the pernieum or their back
4. Neuro abnormalities
5. Enlarged thyroid

Question 15

What is the management of constipation?

Answer 15

1. Start with disimpaction
   Start with oral route-polyethylene glycol solution (20-25ml/kg/hour)
   Or movicol
   Rectal route-enema 3 times a day
2. Then maintenance:
   Osmotic laxative like sorbitol or lactulose
3. Dietary modification with increased fiber and fluids
4. Counsel the parents and child
5. Anal fissure: use anaesthetic creams

Question 16

What is encoperesis?

Answer 16

It is faecal in continence or soiling which is either involuntary or voluntary in places that are socially and culturally unacceptable to the child

Question 17

What are the two categories of encoperesis?

Answer 17

1. Retentive and non retentive

Question 18

What is retentive encoperesis?

Answer 18

It occurs 80% of the time and it means that there is a functional cause to the constipation

• history of large diameter stools
• passing painful stool

Question 19

What do we look for in history for encoperesis?

Answer 19

1. Neurological: do they have CP, hypotonia, intellectual disability etc.
2. Do they have constipation?
3. Do they have psychosocial problems like schedule changes, separation, emotional stress

Question 20

What do we look for in the physical exam?

Answer 20

1. Abdominal exam: faceal mass
2. Rectal exam: they might have decreased anal tone
3. Perineum: anterior displacement of the anus
4. Neuro exam: weak lower limbs, anal wink test
5. Lower back to look for lipoma

Question 21

What special investigations do we do in encoperesis?

Answer 21

And X-ray

Question 22

What is the DSM V criteria for encoperesis?

Answer 22

1. Child has to be at least 4 years
2. Repeated passage of farces into inappropriate places like the floor or clothing involuntary or voluntary
3. Have at least one event in one month every month
4. Their behavior is not caused by a laxative or any other medical condition