Constipation and Abdominal Pain

1. Constipation and Abdominal Pain Jennifer Maupin, RN, CPNP-PC Gastroenterology, Hepatology and Nutrition

2. Guideline Resources, Constipation: • Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014; 58:258-274.

3. Guideline Resources, Abdominal Pain: • Vandenplas Y, Rudolph CD et al. Pediatric gastroesophageal reflux clinical practice guidelines: Joint recommednations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009; 49:498-547.

4. Constipation

5. Definition of Functional Constipation In the absence of organic pathology, 2 or more of the following symptoms in a child with a developmental age <4 years • <2 defecations per week • At least 1 episode of incontinence per week in a child that was previously potty trained • History of excessive stool retention • History of painful or hard bowel movements • Presence of a large fecal mass in the rectum • History of large-diameter stools that may obstruct the toilet

6. Definition of Functional Constipation • In a child with a developmental age >4 years and insufficient criteria for irritable bowel syndrome: • <2 defecations in the toilet per week • At least 1 episode of fecal incontinence per week • History of retentive posturing or excessive volitional stool retention • History of painful or hard bowel movements • Presence of a large fecal mass in the rectum • History of large-diameter stools that may obstruct the toilet

7. Assessment • History • Onset of symptoms • Stool consistency (Bristol Stool Scale) • Stooling pattern, encopresis • Blood in Stool (not unusual with passage of hard stool) • Abdominal pain • Appetite/weight • Family history of GI problems including constipation

8. Available on-line: • www.gutsense.org • (better than asking, “what does your poop look like?”)

9. Red Flags • Weight loss, poor linear growth • Onset of symptoms in infants <1 month old (ask about passage of meconium at >48 hours of life) • Blood with passage of soft stool • Evacuation of explosive stools after withdrawal of the examining finger on digital rectal exam • Text [Arial 22pt] • Text [Arial 22pt]

10. Differential Diagnosis • Celiac disease • Hypothyroidism, hypercalcemia, hypokalemia • Diabetes mellitus • Dietary protein allergy (milk) • cholinergics, antidepressants, chemotherapy, heavy metal ingestion (lead) • Vitamin D intoxication • Botulism • Cystic fibrosis • Hirschsprung’s disease

11. Differential Diagnosis • Anal achalasia • Colonic inertia • Anatomic malformations (imperforate anus, anal stenosis) • Pelvic mass (sacral teratoma) • Spinal cord anomalies, trauma, tethered cord • Abnormal abdominal musculature (prune belly, gastroschisis, Down syndrome) • Pseudoobstruction (visceral neuropathies, myopathies, mesenchymopathies) • Multiple endocrine neoplasia type 2B

12. Red Flags Onset at <1 month of age Passage of meconium >48 hours of life Family history of Hirschsprung’s Disease Ribbon stools Blood in the stools in the absence of anal fissures or with passage of soft stools Failure to thrive (poor linear growth, poor weight gain)

13. Red Flags Fever (infection? Inflammation?) Bilious vomiting (obstruction?) Abnormal thyroid gland (thyroid dysfunction?) Severe abdominal distention (obstruction?) Perianal fistula (IBD?) Abnormal position of anus

14. Physical Exam Red Flags Absent anal or cremasteric reflex (anal reflex often absent in chronic constipation) Decreased lower extremity strength/tone/reflex (spina bifida?) Tuft of hair on spine (spina bifida?) Sacral dimple (spina bifida? tethered cord?) Gluteal cleft deviation Extreme fear during anal inspection (abuse?) Anal scars (surgical history? Abuse?)

15. Diagnostic Testing • Digital rectal exam: perform based on history • X-ray (KUB): only needed if fecal impaction is suspected or physical exam (DRE) is not possible • Colonic Transit Study (sitz marker test): only useful for evaluating for slow colonic transit • Anorecal manometry: only useful in evaluation of HD and dyssynergia. If no RAIR (rectoanal inhibitory reflex), suction biopsy should be performed to evaluate for HD.

16. Diagnostic Testing • Colonic manometry: evaluates colonic dysmotility, recommend screening for colonic transit before performing manometry • MRI of the spine: if tethered cord or other neurologic abnormalities suspected • Colonic Scintigraphy: useful in measuring colonic motility in children with slow transit constipation.

17. Diagnostic Testing • Routine laboratory testing is not recommended • If suspected, test for: • Thyroid dysfunction: TSH, T-4 • Metabolic dysfunction: Chem 10 • Celiac disease: Celiac panel, IgA • Food allergy: Immunocap • Inflammatory markers: ESR, CRP • Cystic Fibrosis: Sweat test

18. Nonpharmacologic Treatment • Current research does not support the use of: • Fiber • Hydration (fluid) • Physical activity • Prebiotics • Probiotics • Behavioral therapy

19. Nonpharmacologic Treatment • What is recommended: • Normal fiber intake (age based)(fiber gummies are great!) • Normal fluid intake (64 oz/day) • Normal physical activity (1 hour/day) • Patient education demystifying, explaining and providing guidance for toilet training

20. Pharmacologic Treatment • Polyethylene Glycol (Miralax) (OTC) • Enemas (equally effective) (OTC) • Less effective then Miralax: • Lactulose (prescription only) • Milk of magnesia (OTC) • Mineral oil (OTC)

21. Dosing Miralax • Mix 1 capful (17 grams) with 8 oz of liquid • DO NOT mix with milk or soda • Consume within 15-20 minutes (not effective if placed in a sippy cup and consumed over 8 hrs) • Titrate dose to achieve soft, but formed stool. Go as high as it takes. • Text [Arial 28pt] • Text [Arial 22pt] • Text [Arial 22pt]

22. Laxative Regimens • Treatment of fecal impaction: • Miralax 1-1.5 g/kg daily for 3-6 days • Enema daily for 3-6 days • Start daily laxative regimen after completed • Miralax is preferred • Use lactulose, milk of magnesia or mineral oil if Miralax is not available • Combine therapies if a single therapy is not effective

23. Expert Opinion • Maintenance treatment should continue for at least 2 months. • All symptoms of constipation should be resolved for at least 1 month before discontinuation of treatment. • Treatment should be decreased gradually. • In the developmental stage of toilet training, medication should only be stopped once toilet training is achieved.

24. Novel Pharmacologic Therapies • Medications that have been found to be effective in treating constipation in adults. Not currently recommended in children: • Lubiprostone (Amitiza), chloride channel activator • Linaclotide (Linzess), chronic idiopathic constipation tx • Prucalopride (Resotran), serotonin 5-HT4 receptor agonist

25. Surgical Treatment • ACE (cecostomy) The antegrade delivery of cleansing solutions enables the patient to evacuate the colon at regular intervals, avoiding impaction of feces and reducing fecal incontinence.

26. Other Treatment Options • Transcutaneous Nerve Stimulation (TNS) • TNS is a noninvasive and painless form of interferential therapy in which 4 surface electrodes are applied to the skin which produce 2 sinusoidal currents that cross within the body • Evidence does not support the use of TNS in children with intractable constipation.

27. Prognosis of Functional Constipation in Children • Based on study of children referred to pediatric gastroenterologists: After 6-12 months: • 50% will recover and be without laxatives • 10% are well while taking laxatives • 40% will still be symptomatic despite use of laxatives After 5 years: -50% are recovered and no longer taking laxatives After 10 years: • 80% are recovered and no longer taking laxatives • A delay in initial medical treatment for >3 months from symptom onset correlates with longer duration of symptoms

28. Online Resources • “The Poo in You”: 6 minute video available on Youtube or at www.gikids.org • “I go potty”: free app with potty training tips • Squatty Potty: www.squattypotty.com (lol unicorn) • Pedia-lax (www.pedia-lax.com) • Provider resources: • Poop journal • Product information

29. Abdominal Pain

30. Diagnosis • Unless proven otherwise, all pediatric abdominal pain is acid reflux • If it is not GER/reflux, it is most likely constipation

31. History and Physical • Infants and toddlers: There is no symptom or symptom complex that is diagnostic of GERD or predicts response to therapy • Children and adolescents: History and physical examination may be sufficient to diagnose GERD if the symptoms are typical

32. Diagnostic Testing • pH probe and pH/impedance probe testing • May be useful to correlate symptoms (eg, cough, chest pain) with acid reflux episodes and to select those infants and children with wheezing or respiratory symptoms in whom GER is an aggravating factor • Sensitivity, specificity and clinical utility for diagnosis and management of possible extraesophageal complications of GER are not well established

33. Diagnostic Testing • Esophageal manometry • Useful to confirm a diagnosis of achalasia or other motor disorder of the esophagus that may mimic GERD • Not useful to diagnose GERD • Endoscopy and biopsy • Important to identify or rule out other causes of esophagitis (eosinophilic esophagitis), and to diagnose and monitor Barrett esophagus

34. Diagnostic Testing • Barium contrast radiology (UGI) • Not useful for the diagnosis of GERD • Useful to confirm or rule out anatomic abnormalities of the upper gastrointestinal tract that may cause symptoms similar to those of GERD • Nuclear scintigraphy (gastric emptying scan) • Not useful for the diagnosis of GERD • Recommended only in individuals with symptoms of gastric retention

35. Diagnostic Testing • Esophageal and gastric ultrasonography • Not recommended for the routine evaluation of GERD in children • Abdominal US is useful for evaluating pyloric stenosis in infants

36. Diagnostic Testing • Tests on ear, lung and esophageal fluids • Evaluation of middle ear or pulmonary aspirates for lactose, pepsin, or lipid-laden macrophages have been proposed as the tests for GERD. No controlled studies have proven that reflux is the only reason these compounds appear in ear or lung fluids, and no controlled studies have shown that the presence of these substances confirms GER as the cause of ear, sinus, or pulmonary disease

37. Diagnostic Testing • Empiric trial of acid suppression as a diagnostic test • Expert opinion suggests that in an older child or adolescent with typical symptoms suggesting GERD, an empiric trial of PPIs is justified for up to 4 weeks • Symptom improvement does not confirm a diagnosis of GERD • There is no evidence to support an empiric trial of acid suppression as a diagnostic test in infants and young children where symptoms suggestive of GERD are less specific

38. Treatment • Lifestyle changes • Infant: reflux precautions (hold upright x 20 minutes after eating, feeding smaller volumes more frequently), elemental formulas, thickening formula • Children and adolescents: Prone or left-side sleeping position and/or elevation of the head of the bed may decrease GER. There is no evidence to support the routine elimination of any specific food for management of GERD. In adults, obesity, large meal volume, and late night eating are associated with symptoms of GERD.

39. Treatment • Pharmacologic therapies: • Histamine-2 Receptor Antagonists • Tagamet (cimetidine): 10-15 mg/kg/dose 4x/day, before meals and at bedtime • Zantac (ranitidine): 3-5 mg/kg/dose 2-3x/day, before meals and at bedtime Rapid onset of action, useful for on-demand treatment. Tachyphylaxis (tolerance) is a drawback to chronic use.

40. Treatment • Pharmacologic therapies: • Proton Pump Inhibitors: • Prilosec (omeprazole): 0.7 – 3.3 mg/kg/day, 1-2x/day • Prevacid (lansoprazole): 1.4 mg/kg/day, 1-2x/day • Protonix (pantoprazole): 1 mg/kg/day, max 40 mg/day • Aciphex (rabeprazole): Pediatric doses not defined • Nexium (esomeprazole): Pediatric doses not defined PPI’s are superior to H2RAs. No PPI has been approved for use in infants younger than 1 year of age.

41. Treatment • Pharmacologic therapies: • Prokinetic therapy: • Reglan (metoclopramide): 0.1 mg/kg/dose 4x/day • Propulsid (cisapride): 0.2 mg/kg/dose 4x/day • Erythromycin (eryped): 3-5 mg/kg/dose, 3-4x/day • Bethanechol (urecholine): 0.1-0.3 mg/kg/dose 3-4x/day • Domperidone: Pediatric doses not defined There is insufficient evidence of clinical efficacy to justify the routine use of metoclopramide, erythromycin, bethanechol, cisapride or domperidone for GERD.

42. Treatment • Pharmacologic therapies: • Buffering agents: • Carafate (sucralfate): 40-80 mg/kg/day, 4x/day PRN • Sodium alginate (algin): 0.2 – 0.5 mL/kg/dose, 3-4x/day Useful on demand for occasional heartburn. Chronic use of buffering agents or sodium alginate is not recommended for GERD because some have absorbable components that may have adverse effects with long-term use

43. Treatment • Surgical therapy: Nissen Fundoplication • Indications for surgery • Failure of optimized medical therapy • Dependence on long-term medical therapy • Pulmonary aspiration of refluxate • Respiratory complications (asthma, frequent pneumonia) Before surgery it is essential to rule out non-GERD causes of symptoms and ensure that the diagnosis of chronic-relapsing GERD is firmly established.

44. Red Flags • Fever:

45. Red Flags • Fever: infection, inflammatory bowel disease (IBD)

46. Red Flags • Fever: infection, inflammatory bowel disease (IBD) • Hematochezia:

47. Red Flags • Fever: infection, inflammatory bowel disease (IBD) • Hematochezia: milk protein allergy (infants), IBD

48. Red Flags • Fever: infection, inflammatory bowel disease (IBD) • Hematochezia: milk protein allergy (infants), IBD • Weight loss:

49. Red Flags • Fever: infection, inflammatory bowel disease (IBD) • Hematochezia: milk protein allergy (infants), IBD • Weight loss: IBD, gastroparesis

50. Red Flags • Fever: infection, inflammatory bowel disease (IBD) • Hematochezia: milk protein allergy (infants), IBD • Weight loss: IBD, gastroparesis • Localized pain, right side: