Constipation, Encopresis, Diarrhea

1. Constipation, Encopresis, Diarrhea Abbey Rupe, MD 2.7.12

2. Definitions • “Rome III” diagnostic categories of functional disorders of defecation in children: • Functional constipation • In infants and preschool children • In children 4-18 years of age • Infant dyschezia • Nonretentive fecal incontinence

3. Functional constipation--Dx • Infants and toddlers: 2 or more of the following present for at least 1 month: • 2 or fewer defecations/week • At least 1 episode of incontinence after being toilet trained • Hx of excessive stool retention • Hx of painful or hard bowel movements • Presence of large fecal mass in the rectum • Hx of large-diameter stools that may obstruct the toilet

4. Functional constipation--Dx • Children w/ developmental age 4-18 yrs; at least 2 of the following present for at least 2 months: • 2 or fewer defecations/week • At least 1 episode of fecal incontinence/week • Hx of retentive posturing or excessive volitional stool retention • Hx of painful or hard bowel movements • Presence of a large fecal mass in the rectum • Hx of large-diameter stools that may obstruct the toilet

5. Functional vs Organicconstipation • Organic causes: < 5% of cases • Anatomic: anal stenosis, imperforate anus • Metabolic/GI: hypothyroidism, CF, diabetes mellitus, celiac disease • Neuropathic: spinal cord abnormalities, tethered cord • Intestinal nerve/muscle disorders: Hirschsprung disease, neuropathies • Misc: cow’s milk protein intolerance, lead ingestion, vit D intoxication, botulism

6. Functional constipation-etiology • 3 periods when kids prone to develop constipation: • Introduction of cereals and solid food to infant’s diet • Toilet training • Starting school

7. Functional constipation--causes • Painful defecation • Can start a vicious cycle • Toilet training • Stool is held for longer periods between BMs • Power struggles can develop • Diet • Highly processed foods consumed at the expense of fruit, veggies, and fiber • Cow’s milk and constipation???? controversial

8. Evaluation • History • Delayed passage of meconium • Painful defecation • Blood on stool • Toilet training issues • Voiding dysfunction and enuresis • Diet • Changes at home/school • Family hx

9. Evaluation • Hx: signs suggesting possible organic cause: • Weight loss or poor weight gain • Anorexia • Delayed growth • Delayed passage of meconium (after 48 hours) • Urinary incontinence • Passage of blood (unless due to anal fissure) • Constipation present since birth/early infancy • Acute constipation • Fever, vomiting, diarrhea • Extraintestinalsx

10. Evaluation • Physical exam • Abdominal distention • Mass in suprapubic area • Anal fissure • Soiled underwear • Anal sphincter tone • Size of rectal vault • Impacted stool • Lower back skin defects

11. Evaluation • PE findings suggestive of organic cause: • FTT • Abdominal distention • Lower spine abnormalities • Anteriorly displaced anus • Tight, empty rectum in presence of palpable fecal mass • Absent anal wink • Absent cremasteric reflex • Decreased lower extremity tone or strength

12. Evaluation • Laboratory (if indicated) • KUB • CBC • Thyroid • Celiac disease panel • Barium enema • Anorectalmanometry • Rectal biopsy • Motility studies • Sweat chloride

14. Evaluation • Findings supportive of functional etiology: • Onset coincides with dietary changes, toilet training, or painful bowel movements • Stool withholding behavior • Good response to conventional treatment

15. Infants: Constipation vs normal stooling • Breast-fed infants: average 3 stools/day • Range: BM with every feed to BM every 7-10 days • Formula-fed infants: • Average 2/day • Can vary with formula • Soy-based—tend to produce harder stools; hydrolyzed casein formulas tend to produce looser stools

16. Infants • Grunting, apparent straining, turning red in the face, etc does not necessarily mean an infant is constipated • More appropriate measure is consistency of the stool • Efforts >10 minutes to produce soft stool: “infant dyschezia” – failure to relax pelvic floor during defecation effort; resolves spontaneously with time

17. Infants • “normal” stools • Reassure, reassure, reassure • Press on feet, press knees to belly, raise vertical, etc • Constipated: • 1 tsp dark Karo syrup bid • Miralax • Glycerin suppository • Juice—pear, apple, prune • If on solids: • increase pear, prune, plums, beans, peas, peaches • Decrease rice cereal, applesauce, bananas

18. Treatment of Children • Goal: 1 soft, easily passed stool daily • Education • “cycle” of constipation • Length of treatment • Safety of medication used • 3 phases: • Disimpaction • Maintenance • Follow-up

19. Disimpaction • Options: oral or NG medications, rectal medications, or combination • Inpatient vs outpatient • Oral: • Polyethylene glycol (Miralax) • Polyethylene glycol-electrolyte solution • Mineral oil (don’t use if at risk for GER) • Other: magnesium hydroxide, magnesium citrate, lactulose, sorbitol, senna, bisacodyl

20. Disimpaction • Rectal • Phosphate sodium enema (2 yrs and older) • Mineral oil enema • Bisacodyl suppository (older children) • Glycerin suppository (infants)

21. Maintenance • Polyethylene glycol • Magnesium hydroxide • Lactulose • Mineral oil

22. Medications • Polyethylene glycol (PEG 3350, Miralax) • Osmotic laxative • OTC • 0.4-0.8 grams/kg/day • Mix in 4-8 ounces liquid • Increase or decrease by ½ to 1 tsp every other day until stools soft and daily

23. Medications • Mineral oil • Lubricant laxative • ? Interfere with absorption of fat soluble vitamins • Administer in mid-afternoon and bedtime • +/- give multivitamin • More palatable if chilled and served with a fat-containing food the child likes (pudding, yogurt, ice cream, chocolate syrup) • Avoid in kids < 1 yr of age and those at risk for GER (aspiration pneumonitis)

24. Medications • Other osmotic laxatives: • Milk of magnesia • Lactulose • Stimulant laxatives • Senna, bisacodyl

25. Maintenance • Behavior modification: • “scheduled sitting” on the toilet for 5-10 minutes at same time each day (preferable within 30 minutes after a meal) • Provide footstool for support if needed • Reward system • “Poop Journal”

26. http://pedia-lax.com/constipation-education

27. Maintenance/prevention • Dietary changes • Increase intake of fruit, raw veggies, bran, whole-grain breads, cereals, and fluids other than milk • Cow’s milk • Consider 1-2 week trial of elimination in atopic children whose constipation is unresponsive to other measures • ?probiotics

28. Maintenance/prevention • When to discontinue medications? • Depends on child and severity of constipation • Taper gradually, resume if constipation returns

29. Encopresis/fecal incontinence • Constipation with fecal incontinence—80-95% • Nonretentive fecal incontinence—5-20% • Rome III criteria: • Children with developmental age of >4 yrs, with all the following present for at least 2 months: • Defecation into places inappropriate to the social context at least once/month • No underlying disease process to explain the symptoms • No evidence of constipation

30. Constipation-associated fecal incontinence • Manage as you would for severe constipation

32. Non-retentive fecal incontinence • Causes: unclear • Some association w/ behavioral and attention problems as well as anxiety and depressive symptoms • Soiling episodes often linked to certain persons or situations • Up to 40% have never been fully toilet trained

33. Non-retentive • Treatment: • No widely effect treatments  • Behavior modification • Highly structured toilet training protocol aimed at frequent efforts at defecation • Reward system • Psychosocial diagnosis and support • Outcome: • one study found 29% resolution at 2 yrs, 65% after 5 yrs, and 90% after 10 years

34. Indications for referral • Consider when oral and/or rectal medications are ineffective for disimpaction or when dietary and laxative therapy are ineffective • Complete laboratory data prior to consultation (thyroid, calcium, celiac disease, lead) • Referral options: • Wichita: 2 peds gastroenterologists • Children’s Mercy: peds GI, BRICK clinic

35. Constipation questions?

36. Diarrhea • Acute • Passage of loose or watery stools at least 3x/day in a 24-hour period • Lasts <14 days • Chronic • Stool volume of >10 gm/kg/day (infants/toddlers) or >200gm/day (older children) x14 or more days • Typically means: loose or watery stools occurring at least 3x/day

37. Acute diarrhea • Etiology • Infectious gastroenteritis • Acute watery diarrhea • Rotavirus (infants/young children) • E. coli (older children) • Invasive (bloody) diarrhea—frank blood in stool + fever • Shigela • Salmonella • Campylobacter • EHEC • EIEC • Other: influenza, HIV, pneumonia, UTI, meningitis, sepsis

38. Acute diarrhea • Assessment: • Type of diarrheal illness (watery, invasive, chronic) • Assess hydration • Assess comorbid conditions

39. Assess hydration status (WHO)

40. Diagnostic studies • Not indicated in most cases • Dehydration requiring IVF • Stool studies: • Viral antigen (rota) • Culture (bloody diarrhea) • O and P (recent travel) • C. diff (recent abx)

41. Treatment—acute watery diarrhea • Fluid and electrolytes • Replacement • Maintenance • < 2 yrs: 50-100 ml ORS/episode of V/D • > 2 yrs: 100-200 ml ORS/episode of V/D • Oral Rehydration Solution • Mixture of water, salts, and glucose • Pedialyte, etc • IVF • Rehydrate with NS boluses (20 ml/kg), followed by dextrose-containing IVF

42. Treatment--AGE • Refeeding • Feeding can be resumed as soon as rehydration is complete • Feed age-appropriate diet • BRAT is unnecessarily restrictive

43. Treatment--AGE • Pharmacotherapy • Antibiotics—not indicated • Antidiarrheal—not recommended • Antimotility (i.e. loperamide)—not recommended due to side effects (lethargy, CNS depression, etc) • Antisecretory (i.e. bismuth)—contain salicylates (EVEN Children’s PeptoBismol) • Probiotics • Reduce stool output and diarrhea duration • Antiemetics--controversial

44. Chronic diarrhea • Post-enteritis syndrome • Most acute enteric infections resolve within 14 days • Occasionally, acute GE can cause mucosal damage to small intestine and trigger chronic diarrhea • ? Secondary to transient lactase deficiency • Probiotics may speed recovery

45. Chronic diarrhea • DDx list is HUGE! • Functional • Excessive juice/osmotically active carb intake • Idiopathic • Enteric infection • Postentereitis syndrome • Parasites • Bacteria • Viruses • CMV, rota, HIV

46. Chronic diarrhea • DDx, cont’d • CF • Immune deficiency • Abnormal immune response • Celiac disease • Food allergic enteropathy • IBD • Protein losing gastroenteropathy • Factitious diarrhea

47. Chronic diarrhea • Lab • Celiac serology (anti-tTG) • Stool pH, electrolytes, reducing substances • Occult blood and leukocytes • Stool fat • Concern for IBD: CBC, albumin, ESR • Sweat chloride • Fecal elastase

48. “Toddler’s Diarrhea” • Aka Functional Diarrhea or Chronic nonspecific diarrhea of childhood: • Painless passage of 3 or more large, unformed stools during waking hours for 4 or more weeks • Onset in infancy or preschool years • Without FTT or specific definable cause

49. Toddler’s Diarrhea • Early morning stools: large and semi-formed • Stools become progressively looser as day progresses • Nearly all will develop normal bowel patterns by 4 yrs of age

50. Toddler’s Diarrhea • Sometimes due to excessive intake of fruit juice • Improves if intake is decreased • No other dietary modification needed