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ChronicConstipation:
Update inManagement
Abdulwahab Telmesani
FRCPC,FAAP
Faculty of Medicine andMedical Science
Umm Al-Qura Uniersity
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Chronic constipation
3% of the visits to general pediatrics.
25% of the visits to pediatrics G.I.
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Defnition
Infrequent stool
Hard stool Large stool
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Defnition
NASGAN!
A dela" or difficult" in defecationpresent for 2 or #ore $ees and
sufficient to cause significant distress
to the patient.
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Normal requency o bowelmovement
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Epidemiology:
&he prevalence of childhood constipation
in the general population ranged fro#
'.(% to 2).*%
Maarte M! et al
"m # $astroenterol %&&'
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Epidemiology:
constipation correlated $ith lo$ #aternal
education+ fe#ale se,+ living in a large
co##unit" and having no older si-lings.
#(N") * et! al! "cta +,diatrica-%&&'
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E.clusive breast edbabies
In conclusion+ infrequent -o$el #ove#ents in
"oung infants fed e,clusivel" -reast #il can
-e a har#less pheno#enon that can easil"
diagnosed -" histor" and careful e,a#ination
of the infant.
/on 0o Choe et al Eur # +ediatr1%&&23
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*unctional constipation in infants: a ollow4up study
e conclude that #ost infants $ith severe
constipation evaluated at a tertiar" center arerecovered after * #onths. /arl" therapeutic
intervention #a" -eneficiall" contri-ute to the
resolution of constipation. van den 5erg MM et al # +ediatr
%&&6
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7rend in amily 8 $enetic
ro#inent fa#il" histor" of constipation.
Identical t$ins have * ti#es foldspossi-ilit" than non identicals.
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Chronic constipation
0unctional 1 non organic is #ost
co##on
rganic is rare e,cept in infanc"4
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*unctional 8 non organicconstipation
hat cause it 1 start it
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*unctional 8 non organicconstipation
Inappropriate toilet training
Anal fissure 1 Anusitis
Avoidance of response to nature call
Inconvenient 1 unco#forta-le places
6ehavioral
7icious c"cle of retention develop#ent.
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Encopresis:
Incontinence of stool of non organic
rigin rare -efore 3 "ears4
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(rganic Causes o
Chronic constipation:
hat are the causes
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Chronic constipation inchildren: (rganic disorders
are a maor cause
A significant nu#-er of the children $ith
chronic treat#ent8resistant constipation #a" have organic causes slo$ colonic transit and
outlet o-struction4 and suggests ne$
approaches to the #anage#ent of children $ith chronic treat#ent8resistant constipation.
59 )outhwell et al J. Paediatr. Child Health1%&&63
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Stool $ithholding presenting as a cause of
non8epileptic sei9ures
"nthony Cohn
DevelopmentalMedicine and Child Neurology; (ct %&&6
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chronic constipation andood hypersensitivity
An increasing nu#-er of reports suggest a
relationship -et$een refractor" chronicconstipation and food allerg" in children.
CARRCC! " #. !ACN
"limentary +harmacology 7herapeutics %&&'
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Evaluation
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Evaluation
Histor".
h"sical e,a#ination.
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0istory::econiu# passage.
0requenc" of -o$el #ove#ent.
;iet. School 1 travel.
ainful defecation.
0a#il" histor". 0&&.
<logging of the co##ode.
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+hysical e.amination:
Gro$th
A-d. ;istention
0ecal #ass felt on a-d. e,a#.
=ectu# full of stool
0ecal soiling.
Anogenital inde,
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"nogenital inde.:
;istance in centi#eters!
fro# the vagina or scrotu# to the anus
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
fro# the vagina or scrotu# to the cocc",.
0e#ales! '.3) ? '.')+
:ales! '.5* ? '.2.
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+hysical e.amination:
Anal fissure 1 anusitis.
Signs of trau#a a-use4.
Signs of spinal defects spina -ifida4
Neurological assess#ent of L.L. and
anal $en
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Myelomeningocele
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)pina bifda
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7ethered cord syndrome
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Neurofbromatosis
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;nvestigations
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;nvestigations:
Non is required routinely.
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;nvestigations:
Stool analysis ??? Whyyyy
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;nvestigations:
lain a-do#inal @ =A. o-ese child
or refusing e,a#4
Lu#-osacral @ =A 1 :=I
6a. /ne#a
=ectal -iops".
&B+ Na+ C+ s#olalit".
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;nvestigations:
Anorectal #ano#etr".
Anal sphincter /:G.;efecograph".
<olorectal transit stud".
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Management
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Management:
Evaluation and Treatment of Constipation in
Infants and Children: Recommendations ofthe North merican Society for !ediatric
"astroenterolo#y$ %epatolo#y and Nutrition
D<linical ractice GuidelineE # +ediatr $astroenterol Nutr %&&' )ep< =ol!
2> 1>3- pp! e?4?>!
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Management:
/ducation.
;isi#paction.
:aintenance.
6ehavioral #odification.
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Education:
/ducate the fa#il" and the child if
possi-le!
athoph"siolog"
&hat incontinence is not $illful.
Fse dra$ings to e,plain.
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Disimpaction:
0ecal i#pact evacuation!
hosphate ene#a fleet ene#a4ral #edication e.g. #ineral oil
paraffin oil4+ pol"eth"lene gl"col
/G335'4 or -oth
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Maintenance:
:ieral oil paraffin oil4 83 #l1g1da"
ol"eth"lene gl"col /G 335'4
electrol"te free g1g1da"
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Maintenance:
Lactulose+ :g h"dro,ide+ Sor-itol+
others have -een usedn and off la,atives e.g. Senna
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Maintenance:
In case of anal fissure+ appl"
petroleu# gel to anal areafrequentl"
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Maintenance:
Increase dietar" fi-ers
rune JKM
ear Ouice
Apple Ouice
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" comparative study: 7he e@cacyo
liquid para@n and Aactulose inmanagement o chronic unctionalconstipation
Liquid paraffin is #ore effective in the treat#ent
of children $ith constipation.
N"*;/E U9$"NC; et al
Pediatrics !nternational 1%&&63
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5ehavioral modifcation:
=egular toilet ha-it after #eals4
Ceep diar" and record use calendarand stars4
:otivation avoid negative co##ents4
Consultation with
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Consultation withspecialist:
ediatric G.I. <eliac disease+ etc.4
/ndocrine h"poth"roidis#+ etc.4
Nephrolog" dia-etes insipidus4
ediatric surger" Herschsprung4
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5ioeedbacB:
Lac of coordinated rela,ation of
e,ternal sphincter $hile defecationn #ano#etr"
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5ioeedbacB:
&here is no evidence that -iofeed-ac
training adds an" -enefit to conventional
treat#ent in the #anage#ent of
functional fecal incontinence in children
5raelli- M et al
7he Cochrane
Aibrary- Copyright %&&'
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)urgical 7reatment:
Anorectal #"ecto#"
&he :alone appendicocecoso#" forretrograde irrigation4
Aong47erm (utcome o
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Aong 7erm (utcome o*unctional Childhood
Constipation <hildhood constipation appears to -e a
predictor of I6S in adulthood.
)eema han et al Digestive
Diseases )ciences< #an %&&
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&han "ou
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%irschsprun# &isease
'requency In the (S: Hirschsprung disease occurs
in appro,i#atel" per 5''' live -irths.
!athophysiolo#y: Hirschsprung disease results fro# the a-sence of paras"#pathetic ganglion
cells in the #"enteric and su-#ucosal ple,us
of the rectu# and1or colon.
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