Chronic Constipation: A hard problem Dr.Fawaz AlRefaee, MBBS FAAP FRCPC Pediatric Gastroenterologist,Al Adan Hospital 1st Jahra Pediatric Conference February 6,2016

Objectives • Definition of constipation • Epidemiology • Etiology • Treatment • Prognosis • What’s New? • Take Home Points

Definition • Rome III (2006) - Functional Constipation - 2 or more of the following*: • Two or fewer 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 *N.B.: Criteria fulfilled at least once per week for at least 2 months Emphasis is changing: Difficulty with defecation rather than number of stools

Normal Frequency of Bowel Movements/Week by Age 40 35 30 25 5% 20 mean 95% 15 10 5 0-3 months 6-12 months 1-3 years >3 years Fontana M. Bianch C, Cataldo F, et al. Bowel frequency in healthy children. Acta Paediatr Scand 1987;78:682-4.

Epidemiology : • Prevalence: 0.7-30%, with median 8.9% • Higher prevalence 2-6 year olds compared to older children • Highest prevalence 5-6 years (35.4%) • Often at times of change in routine • Prevalence rates similar for boys and girls • In adults, prevalence higher for women • Represents 3% of visits to a general pediatrician and up to 25% to a pediatric gastroenterologist • Parents afraid of “something wrong” or “dangerous”

Epidemiology: constipation correlated with low maternal education, female sex, living in a large community and having no older siblings. JONAS F et. al. Acta Pædiatrica, 2006

Exclusive breast fed babies In conclusion, infrequent bowel movements in young infants fed exclusively breast milk can be a harmless phenomenon that can easily diagnosed by history and careful examination of the infant. Yon Ho Choe et al Eur J Pediatr (2004)

Differential Diagnosis • Functional/nonorganic • Anatomic/developmental • Anal (stenosis or ring, ectopic/imperforate anus, mass) • Spinal (meningomylocele, tumor, tethered cord, compression) • Hirschsprung’s disease • Metabolic • Lead, medications, e.g. sympathomimetics, anti-depressants • CF • Hypothyroid, hypercalcemia, hypokalemia • Infant botulism in infants • Food intolerance • Celiac • Cow’s milk protein intolerance • Other - connective tissue disorders, abn. abdominal musculature

History • Frequency and consistency of stools - age at onset, change in pattern over time • Toilet training experience • Withholding behavior • Pain or bleeding with defecation • Abdominal pain • Other symptoms - nausea, vomiting, weight loss • Perianal disease • Current medications • Previous evaluation and treatment • Assessment of adherence

Withholding A description: The body becomes stiff . They cross their legs, tighten their gluteal muscles, walk on tiptoes or hold on to the furniture. Some even squat or hide. Parents often misinterpret the behavior as an effort to push. After successful attempts to withhold, the urge to defecate disappears, and the rectum becomes dilated and filled with fecal material. Soiling may then occur.

Physical Examination • General examination to detect possible underlying disease • Abdominal examination • Neurological examination • Examination of perineum • Digital examination

Hirschprungs • 1/5000 live births • Failure of neural crest cells to populate distal colon and permit relaxation • Usually present in neonatal period • Explosive expulsion of gas and stool after the digital rectal examination • Diagnostic studies • May only involve sphincter

Spina bifida

Myelomeningocele

Investigations Plain abdominal X RAY. ( obese child or refusing exam) Lumbosacral X RAY / MRI Ba. Enema Rectal biopsy. T4, Na, K, Osmolality. Celiac screening (TTG IgA and IgA level)

KUB - Useful? • Several different scoring systems • Retrospective review by Pensabene, et al. found poor inter-observer reproducibility and concluded KUBs of limited value (JPGN 2010; 51:155-9) • May be helpful in documenting status when physical examination is limited or impossible • Absence of stool retention in a child with fecal soiling should prompt referral to psychologist

Elements of Treatment • Education and demystification • Optimizing diet - fiber and fluid • Behavioral modification • Calendar • Sitting schedule • How often? Before school, after school, after dinner • How long? 5-10 minutes • Adherence with medicines • Medical therapy

Maintenance Agents and Doses Lubricants Mineral Oil 1-3 ml/kg/d, in 1-2 doses Osmotics Lactulose 1-3 ml/kg/d, in 1-2 doses Sorbitol 1-3 ml/kg/d, in 1-2 doses Magnesium hydroxide 1-3 ml/kg/d (400 mg/5ml conc) in 1-2 doses Lavage PEG 3350 0.4-1 g/kg/d in 1 dose Stimulants Senna 2-6 y: 2.5 -7.5 ml qd 6-12y: 5-15 ml qd Bisacodyl > 2y: 1-3 tabs(5 mg tabs)/dose 1-2 times/d

Case • 6 year male with 2 year history of what appears to be functional constipation. He has failed therapy with PEG, milk of magnesia, lactulose, and mineral oil.

Importance of Disimpaction • Impaction is defined as a hard mass in the lower abdomen, a large amount of stool in the rectum, or excessive stool on plain abdominal films • Disimpaction is the first step in successful medical therapy - without it, many otherwise effective agents will not work • Options • Oral - mineral oil, PEG solutions, magnesium hydroxide, magnesium citrate, lactulose, sorbital, senna, bisacodyl - alone or in combination • Rectal - enemas or suppositories - avoid soap suds, tap water, or excessive phosphate soda enemas

Rectal vs. Oral Disimpaction • Bekkali, et al. Pediatrics 2009;124:e1108-15 • 90 impacted children 4-16 years old randomized to enemas or PEG • Equally effective • More incontinence and watery stools in PEG group • Comparable behavioral scores

Treatment in Intractable Cases • New pharmacologic agents - lubiprostone • Botox for isolated sphincter dysfunction • Surgical therapy - ACE • Probiotics • Transcutaneous stimulation

Prognosis • Studies: • Only 50% recovered within one year and 65 to 70% within 2 years (Curr Op Ped 1994;6:556) • Other studies show that 5-10 years out, up to 30% still on laxatives (Dig Dis Sci 1994; 39:561) • 418 patients. F/U > 95% (mean 5 years; 1-8 yrs) Success: 60% at 1 year, 80% at 8 years (Gastro 2003; 12:357) • Success rate higher in those without encopresis, or onset > 4yrs • 50% experienced at least 1 relapse • In those > 16 years, constipation persisted in 30% Prolonged treatment is required and course usually complicated by frequent relapses

Take Home Points expert recommendations to evidence based treatments • Most children with constipation do not have an underlying organic disorder • History and physical exam are usually sufficient to make the diagnosis • Tests are indicated to exclude specific diagnosis • Treatment of constipation in children is evolving from expert recommendations to evidence based treatments • PEG based solutions have become the mainstay of therapy

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