The Silent Giant. The Big Brown Elephant in the room: Constipation… Does it make you want to run and hide? Or leave it for someone else to sort out?
Join us for a structured approach to the diagnosis and management of constipation. And let us know your favourite recipe, or a few poo pearls…
Outline: Constipation PEMcast
[cp] Intro & welcome to the PooCast; disclaimer
[et] Background / relevance
Definition (infrequent passage of hard stools) vs wide range of normal (rule of ten):
“difficulty in defecation for 2 weeks or more”
“painful passage of stools”
[mc] Incidence – the Silent Giant
Common! About 1/3rd of kids will have constipation at some time in their life
7% of ED visits (as primary complaint)
[et] Differential diagnoses & their features
- Most are Idiopathic (“Functional”): should not have significant pain / tenderness
- Hirschprung’s Disease – presents as neonate or from birth (10% of those delayed passage of meconium >48hrs), diagnosed on rectal biopsy (by Paediatric Surgeon)
- Imperforate anus
- Spinal dysraphism
- Metabolic (thyroid, calcium)
- Medications (opiates)
- Bowel obstruction including intussusception
[cp] Presenting symptoms
- decreased stool frequency
- painful / difficult passage of stool
- bleeding (fissure)
- “diarrhea” from overflow incontinence
- abdo pain – colicky / crampy – exclude other causes
- decreased appetite
- grumpiness/irritability
[mc] Other history
- Delayed passage of meconium? (Hirschsprung’s)
- Frequent respiratory infections or Failure to Thrive (Cystic Fibrosis)
- Abdominal distension
- Bilious vomiting
- Systemically unwell
- Urinary incontinence
- Dehydration risks: recent illness, fluid intake, (weather, exercise), diet
- Usual abdo pain questions
[et] Signs on Examination
- General appearance, hydration
- Abdo examination:
- distension
- tenderness
- palpable lumps (indentable, in LLQ)
- Back: signs of spinal dysraphism
- Legs: neurologic examination
[cp] Investigations
Usually none
AXR controversy: radiation risk (7 CXRs, from XRayRisk.com) vs aid to compliance,
Piggy-Bank concept: $1 in, 50c out…
Dangerous allure of “The Magic of Tests”
Freedman 2013: AXR associated with other diagnoses ?reflecting diagnostic uncertainty
Investigations when alternative diagnosis suspected
Management
Disimpaction, Maintenance, Behaviour modification
[mc] Education: Longer-term follow-up, supportive attitude, star charts, understanding of stretched bowel (long-term), dedicated clinics, consistent message
[et] Dietary advice: fruit, vegetables, fibre, fluid intake, brown pasta/rice, skin on fruits
[timestamp 23:49]
[cp] Types/classes of medications (options) & how they work, pro’s & con’s
[mc] Stool softeners (docusate, paraffin oil)
[et] Macrogols & Osmotic agents (Poly-Ethylene Glycol 3350 +/- electrolytes, lactulose): titrateable, mixable, “water chaser”
[cp] Lubricants (glycerine suppositories)
[mc] Stimulants (senna, sennosides): can cause cramps, atonic bowel (long term use)
[et] Clearout vs maintenance phase
[cp] Role of enemas (controversy): rarely needed, psychological
[mc] Surgical procedures eg ACE (Antegrade Colonic Enema), caecostomy
[cp] NICE guideline CG99: Constipation in Children & young people (quick overview)
[et] local (PMH) guideline (written action plans)
[mc] other guidelines in the world include Royal Children’s Hospital Melbourne RCH.org.au
[ALL] Personal favourite recipes / approaches
[cp] Summary & goodbye
References
Freedman SB, Thull-Freedman J, Manson D, Rowe MF, Rumantir M, Eltorki M, Schuh S.
Pediatric Abdominal Radiograph Use, Constipation, and Significant Misdiagnoses.
J Pediatr. 2013 Oct 12.
doi:pii: S0022-3476(13)01102-5. 10.1016/j.jpeds.2013.08.074. [Epub ahead of print]
PubMed PMID: 24128647.
