Constipation and IBD

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?
• How hard?
• 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 2 = lumpy and sausage like
• Type 3 = sausage shape with cracks in the surface
• Type 4 = like a smooth sausage or snake
• Type 5 = soft blobs with clear cut edges
• Type 6 = mushy consistency with ragged edges
• 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

Question 7

Why do children become constipated?

Answer 7

• Social
  
  • Poor diet (insufficient fluids, excess milk)
  • Potty training or school toilets issue
• Physical
  
  • Intercurrent illness
  • Medications (opiates and Gaviscon)
• Family history
• Psychological (secondary)
• Organic

Question 8

What is the vicious cycle of constipation?

Answer 8

• Large hard stool
• Leads to pain or anal fissure
• Child withholds stool
• Becomes constipated

Question 9

How does overflow diarrhoea develop?

Answer 9

• Rectum tells them they need to go but the child clenches the external sphincter
• Stool continues to be dehydrated 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

Question 10

Social treatment of constipation

Answer 10

• Explain treatment to parents
• Dietary
  
  • Increase fibre
  • Increase fruit
  • Increase vegetables
  • Increase fluids
  • Decrease milk

Question 11

Psychological treatment of constipation

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

Medical treatment for constipation

Answer 12

• Soften stool and stimulate defecation
  
  • Osmotic laxatives (lactulose)
  • Stimulant laxatives (senna, picolax)
  • Isotonic laxatives (movicol)

Question 13

How is impaction treated?

Answer 13

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

Question 14

How can constipation be confirmed on imaging?

Answer 14

• 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 15

How has the incidence of Crohn’s disease changed in Scottish children?

Answer 15

Dramatic increase

Question 16

What history and examination is required when diagnosing IBD?

Answer 16

• Intestinal symptoms
• Extra-intestinal manifestations (can include erythema nodosum)
• Exclude infection (negative stool culture with 2/52 history)
• Family History
• Growth and sexual development (growth chart plotting and Tanner staging)

Question 17

What laboratory investigations should be carried out for IBD?

Answer 17

• Full blood count & ESR
  
  • Anaemia
  • Thrombocytosis
  • Raised ESR
• Biochemistry
  
  • Stool calprotectin
  • Raised CRP
  • Low Albumin
• Microbiology
  
  • No stool pathogens

Question 18

How does Crohn’s usually present in children?

Answer 18

• Lack of specific symptoms (present with weight loss and growth failure)
• Abnormal blood tests and high calprotectin

Question 19

How does UC usually present in children?

Answer 19

• Symptomatic with bloody diarrhoea
• Do not necessarily have abnormal growth or blood tests
• High calprotectin

Question 20

What are the definitive investigations for IBD?

Answer 20

• Radiological
  
  • MRI (usually >5 years due to the need to keep still without a GA)
  • Barium meal and follow through (younger kids)
• Endoscopy
  
  • Colonoscopy
  • Upper GI endoscopy
  • Mucosal biopsy
  • Capsule endoscopy

Question 21

What are the aims of treatment in IBD?

Answer 21

• Induce and maintain remission
• Correct nutritional deficiencies
• Maintain normal growth and development

Question 22

What are the treatments for IBD in children?

Answer 22

• Medical
  
  • Anti-inflammatory
  • Immuno-suppressive
  • Biologicals (Infliximab)
• Nutritional
  
  • Immune modulation
  • Nutritional supplementation
  • Liquid diet (Crohns)
• Surgical
  
  • Currative in UC
  • Not currative in Crohns