Chronic Constipation and Encopresis Susan Ratliff, MD FAAP April 2, 2009

Constipation Abnormality in the frequency of defecation or in the size or consistency of the feces Abnormality in the frequency of defecation or in the size or consistency of the feces Range of symptoms and signs Range of symptoms and signs Consider constipation a symptom instead of a diagnosis Consider constipation a symptom instead of a diagnosis

Constipation ¼ all cases of chronic constipation begin during the first year of life, highest frequency occurring between ages 2 and 4 ¼ all cases of chronic constipation begin during the first year of life, highest frequency occurring between ages 2 and 4 Males:females 1.5:1 Males:females 1.5:1 Most cases have no precipitating factor Most cases have no precipitating factor

History Normal frequency of defecation Normal frequency of defecation Size Size Consistency of stools passed at different stages Consistency of stools passed at different stages

Stool Frequency Defecation rate higher in breastfed than formula fed infants in early infancy Defecation rate higher in breastfed than formula fed infants in early infancy By 4 mos all infants have a modal frequency of two bowel movements per day By 4 mos all infants have a modal frequency of two bowel movements per day Frequency declines to the “adult” pattern of one stool per day by school Frequency declines to the “adult” pattern of one stool per day by school 96% of 3-4 yr olds have bowel movements between 3 times per day and 3 times per week 96% of 3-4 yr olds have bowel movements between 3 times per day and 3 times per week

Symptoms Abdominal pain Abdominal pain irritability irritability Anorexia Anorexia Abdominal distention Abdominal distention Diarrhea Diarrhea Encopresis Encopresis

Physical exam Abdominal exploration Abdominal exploration Exploration of the sacral region Exploration of the sacral region Exploration of the anorectal region Exploration of the anorectal region –KUB not indicated to establish the presence of fecal impaction if the rectal exam reveals the presence of large amounts of stool

Organic causes of constipation Minority of children but should be recognized early Minority of children but should be recognized early History!!! History!!! –Early onset of constipation (first days of life) –Severe constipation unaffected by medical therapy –Associated features such as vomiting, persistent abdominal distention an failure to thrive

Organic causes of constipation Anatomic disorders of colon and anorectum Anatomic disorders of colon and anorectum –Congenital anal stenosis Severe chronic fecal retention Severe chronic fecal retention Symptoms from an early age Symptoms from an early age Pass small stools Pass small stools –Anterior displacement of anal orifice Onset early infancy Onset early infancy Normal sphincter but abnormally oblique direction of anal canal Normal sphincter but abnormally oblique direction of anal canal –Intraspinal problems Tethered cord, tumors or sacral agenesis Tethered cord, tumors or sacral agenesis –Congenital or acquired colonic strictures NEC or inflammatory bowel disease NEC or inflammatory bowel disease

Organic causes of constipation Motility disorders Motility disorders –Hirschprungs disease Congenital absence of ganglion cells in the myenteric and submucosal plexuses of the GI tract Congenital absence of ganglion cells in the myenteric and submucosal plexuses of the GI tract 1:5000 live births; male:female ratio 3:1 1:5000 live births; male:female ratio 3:1 Misc systemic disorders Misc systemic disorders –Hypothyroidism –Pheochromocytoma –Hypercalcemia –Lead poisoning –Cystic Fibrosis

Functional constipation Most common cause Most common cause Occurs during dietary transition Occurs during dietary transition –Weaning in infancy –Early childhood –Any age? Most commonly caused by painful bowel movements with resultant voluntary withholding of feces Most commonly caused by painful bowel movements with resultant voluntary withholding of feces Prevention with appropriate diet and adequate intake of fluids Prevention with appropriate diet and adequate intake of fluids

Withholding Prolonged faces stasis in the colon, with reabsorption of fluids in an increase in the size and consistency of the stools Prolonged faces stasis in the colon, with reabsorption of fluids in an increase in the size and consistency of the stools Leads to passage of hard stools that painfully stretch the anus Leads to passage of hard stools that painfully stretch the anus This leads to fearful determination to avoid all defecation This leads to fearful determination to avoid all defecation With time this becomes an automatic reaction With time this becomes an automatic reaction The rectal wall stretches and fecal soiling may occur The rectal wall stretches and fecal soiling may occur After several days, irritability, abdominal distention, cramps, and decreased oral intake may result After several days, irritability, abdominal distention, cramps, and decreased oral intake may result

1 yr prospective study of 2144 children <5 yrs of age referred to outpatient clinic with constipation 1 yr prospective study of 2144 children <5 yrs of age referred to outpatient clinic with constipation –48% had history of hard stool, all but three received laxatives 50% were treated with suppositories, enemas or combination of both 50% were treated with suppositories, enemas or combination of both

Lack of structure in management of constipation in preschool children Lack of structure in management of constipation in preschool children Time lapse between onset of symptoms and referral to a specialist Time lapse between onset of symptoms and referral to a specialist Reluctance to increase laxative treatment Reluctance to increase laxative treatment Failure to address parents’ anxieties Failure to address parents’ anxieties

Contributing factors Emotional distress Emotional distress Family distress Family distress Illness Illness Dietary switch from human to cow’s milk Dietary switch from human to cow’s milk Lack of dietary fiber Lack of dietary fiber Changes in Environment Changes in Environment Travel Travel Drugs Drugs

Drugs that can cause constipation Analgesics (NSAIDS) Analgesics (NSAIDS) Anticholinergics Anticholinergics Calcium Channel Blockers Calcium Channel Blockers Iron Supplements Iron Supplements Lead Poisoning Lead Poisoning Opiates Opiates Tricyclic antidepressants Tricyclic antidepressants

Encopresis Involuntary defecation of psychogenic origin Involuntary defecation of psychogenic origin More common in males More common in males Usually appears in children over 4 yrs of age, avg age 4 yrs 7 mos Usually appears in children over 4 yrs of age, avg age 4 yrs 7 mos Associated with recurrent uti and enuresis (disappear when intestinal problems corrected) Associated with recurrent uti and enuresis (disappear when intestinal problems corrected)

Encopresis Need more rigorous therapeutic program for treatment Need more rigorous therapeutic program for treatment –Initial objective is to keep the rectum empty in order to diminish its size, increase rectal sensibility to distention and avoid encopresis

Encopresis First step: rectal disimpaction First step: rectal disimpaction –Hypertonic phosphate enemas or bissacodyl suppositories until evacuation without solid feces Second step: prevent reaccumulation of retained feces and prevent reoccurrence of encopresis Second step: prevent reaccumulation of retained feces and prevent reoccurrence of encopresis –Osmotic laxatives or stimulants or mineral oil in high doses Develop a regular defecation schedule Develop a regular defecation schedule –Take advantage of the gastrocolic reflex (5-15 mins) Manometric feedback? Manometric feedback?

Treatment Dietary changes Dietary changes Bulk forming agents Bulk forming agents Lubricants Lubricants Hyperosmolar agents Hyperosmolar agents

Dietary management High fiber diet High fiber diet –Age + 5= grams of fiber per day –Increase amount gradually to prevent side effects –Fruits, breads and cereals Fluid intake Fluid intake

Bulk-forming agents Increase bulk of the nonabsorbable portion of the intestinal contents to increase the stimulus for peristalsis mimicking the normal course of defecation Increase bulk of the nonabsorbable portion of the intestinal contents to increase the stimulus for peristalsis mimicking the normal course of defecation

Stimulant agents Increase the irritability of the intestinal muscle so that it responds more to distention Increase the irritability of the intestinal muscle so that it responds more to distention

Lubricants Soften the feces and ease defecation Soften the feces and ease defecation Do not initiate defecation Do not initiate defecation

Hyperosmolar Agents Increase the intestinal volume via an osmotic effect Increase the intestinal volume via an osmotic effect

Treatment Simple Constipation Simple Constipation –Dietary measures, bowel habit training Prolonged Constipation Prolonged Constipation –As above –Low dose mineral oil, senna or lactulose Chronic Constipation with Mega rectum and encopresis Chronic Constipation with Mega rectum and encopresis –Fecal disimpaction with phosphate enemas or bisacodyl suppositories –Dietary measures, bowel habit training, high dose mineral oil, lactulose or miralax, psychological support Voluntary fecal incontinence Voluntary fecal incontinence –Psychologic evaluation and treatment

Stepwise approach to treatment Step one: Diet and regular bowel habits Step one: Diet and regular bowel habits Step two: Produce a natural course of defecation with bulk-forming agents or ease defecation with stool softeners Step two: Produce a natural course of defecation with bulk-forming agents or ease defecation with stool softeners Step three: Stimulant laxatives for resistant cases Step three: Stimulant laxatives for resistant cases

Route of administration First step should be oral agents; reserve rectal route for fecal impaction First step should be oral agents; reserve rectal route for fecal impaction

Treatment of infants Increased intake of fluids, particularly juices with sorbitol (prune, pear and apple) Increased intake of fluids, particularly juices with sorbitol (prune, pear and apple) Lactulose, Karo syrup, sorbitol can be used Lactulose, Karo syrup, sorbitol can be used Glycerin suppositories Glycerin suppositories Avoid mineral oil in very young Avoid mineral oil in very young –Lipoid pneumonia

Pediatric dosages of laxatives

Behavioral Modifications Regular toilet habits Regular toilet habits –Unhurried time on the toilet after meals Diaries of stool frequency combined with a reward system Diaries of stool frequency combined with a reward system Referral to mental health provider for behavior modification Referral to mental health provider for behavior modification Requires family that is well organized, can complete time consuming interventions and is sufficiently patient to endure gradual improvements and relapses Requires family that is well organized, can complete time consuming interventions and is sufficiently patient to endure gradual improvements and relapses

Maintenance therapy Mineral oil, sorbitol or MOM Mineral oil, sorbitol or MOM –1-3 cc/kg/day PEG tsp/ 8 oz liquid qd-tid PEG tsp/ 8 oz liquid qd-tid May be necessary for several months May be necessary for several months Only consider discontinuation when the child has been having regular bowel movements without difficulty Only consider discontinuation when the child has been having regular bowel movements without difficulty Relapses are common! Relapses are common!

Prevention Counsel parents on normal defecation habits Counsel parents on normal defecation habits Introduce good dietary habits Introduce good dietary habits –Adequate intake of liquids with only moderate consumption of milk –Balanced fiber-rich diet

References Lowe, Julie and Bruce Parks. “Movers and Shakers: A clinician’s guide to laxatives.” Pediatric Annals ( ). Lowe, Julie and Bruce Parks. “Movers and Shakers: A clinician’s guide to laxatives.” Pediatric Annals ( ). Weaver, Lawrence. “Constipation: Diagnosis and treatment.” Seminars in Pediatric Gastroenterology and Nutrition. Vol 3: Number (1-14). Weaver, Lawrence. “Constipation: Diagnosis and treatment.” Seminars in Pediatric Gastroenterology and Nutrition. Vol 3: Number (1-14). Baker, Susan et al. “Constipation in Infants and Children: Evaluation and Treatment.” Journal of Pediatric Gastroenterology and Nutrition. 29: Baker, Susan et al. “Constipation in Infants and Children: Evaluation and Treatment.” Journal of Pediatric Gastroenterology and Nutrition. 29: Motivational poop posters Motivational poop posters