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

Chronic Constipation and Chronic Constipation and EncopresisEncopresis

Susan Ratliff, MD FAAPSusan Ratliff, MD FAAP

April 2, 2009April 2, 2009

ConstipationConstipation

• Abnormality in the frequency of Abnormality in the frequency of defecation or in the size or defecation or in the size or consistency of the fecesconsistency of the feces

• Range of symptoms and signs Range of symptoms and signs

• Consider constipation a symptom Consider constipation a symptom instead of a diagnosisinstead of a diagnosis

ConstipationConstipation

• ¼ all cases of chronic constipation ¼ all cases of chronic constipation begin during the first year of life, begin during the first year of life, highest frequency occurring between highest frequency occurring between ages 2 and 4ages 2 and 4

• Males:females 1.5:1Males:females 1.5:1

• Most cases have no precipitating Most cases have no precipitating factorfactor

HistoryHistory

• Normal frequency of defecationNormal frequency of defecation

• Size Size

• Consistency of stools passed at Consistency of stools passed at different stagesdifferent stages

Stool FrequencyStool Frequency

• Defecation rate higher in breastfed Defecation rate higher in breastfed than formula fed infants in early than formula fed infants in early infancyinfancy

• By 4 mos all infants have a modal By 4 mos all infants have a modal frequency of two bowel movements frequency of two bowel movements per dayper day

• Frequency declines to the “adult” Frequency declines to the “adult” pattern of one stool per day by schoolpattern of one stool per day by school

• 96% of 3-4 yr olds have bowel 96% of 3-4 yr olds have bowel movements between 3 times per day movements between 3 times per day and 3 times per weekand 3 times per week

SymptomsSymptoms

• Abdominal painAbdominal pain

• irritabilityirritability

• AnorexiaAnorexia

• Abdominal Abdominal distentiondistention

• DiarrheaDiarrhea

• EncopresisEncopresis

Physical examPhysical exam

• Abdominal explorationAbdominal exploration

• Exploration of the sacral regionExploration of the sacral region

• Exploration of the anorectal regionExploration of the anorectal region– KUB not indicated to establish the KUB not indicated to establish the

presence of fecal impaction if the rectal presence of fecal impaction if the rectal exam reveals the presence of large exam reveals the presence of large amounts of stoolamounts of stool

Organic causes of Organic causes of constipationconstipation• Minority of children but should be Minority of children but should be

recognized earlyrecognized early• History!!!History!!!

– Early onset of constipation (first days of Early onset of constipation (first days of life)life)

– Severe constipation unaffected by medical Severe constipation unaffected by medical therapytherapy

– Associated features such as vomiting, Associated features such as vomiting, persistent abdominal distention an failure persistent abdominal distention an failure to thriveto thrive

Organic causes of Organic causes of constipationconstipation• Anatomic disorders of colon and Anatomic disorders of colon and

anorectumanorectum– Congenital anal stenosisCongenital anal stenosis

• Severe chronic fecal retentionSevere chronic fecal retention• Symptoms from an early ageSymptoms from an early age• Pass small stoolsPass small stools

– Anterior displacement of anal orificeAnterior displacement of anal orifice• Onset early infancyOnset early infancy• Normal sphincter but abnormally oblique direction of Normal sphincter but abnormally oblique direction of

anal canalanal canal– Intraspinal problemsIntraspinal problems

• Tethered cord, tumors or sacral agenesisTethered cord, tumors or sacral agenesis– Congenital or acquired colonic stricturesCongenital or acquired colonic strictures

• NEC or inflammatory bowel diseaseNEC or inflammatory bowel disease

Organic causes of Organic causes of constipationconstipation• Motility disordersMotility disorders

– Hirschprungs diseaseHirschprungs disease• Congenital absence of ganglion cells in the myenteric Congenital absence of ganglion cells in the myenteric

and submucosal plexuses of the GI tractand submucosal plexuses of the GI tract• 1:5000 live births; male:female ratio 3:11:5000 live births; male:female ratio 3:1

• Misc systemic disordersMisc systemic disorders– HypothyroidismHypothyroidism– PheochromocytomaPheochromocytoma– HypercalcemiaHypercalcemia– Lead poisoningLead poisoning– Cystic FibrosisCystic Fibrosis

Functional constipationFunctional constipation

• Most common causeMost common cause

• Occurs during dietary transitionOccurs during dietary transition– Weaning in infancyWeaning in infancy– Early childhoodEarly childhood– Any age?Any age?

• Most commonly caused by painful bowel Most commonly caused by painful bowel movements with resultant voluntary movements with resultant voluntary withholding of feces withholding of feces

• Prevention with appropriate diet and Prevention with appropriate diet and adequate intake of fluidsadequate intake of fluids

WithholdingWithholding• Prolonged faces stasis in the colon, with Prolonged faces stasis in the colon, with

reabsorption of fluids in an increase in the reabsorption of fluids in an increase in the size and consistency of the stoolssize and consistency of the stools

• Leads to passage of hard stools that Leads to passage of hard stools that painfully stretch the anuspainfully stretch the anus

• This leads to fearful determination to avoid This leads to fearful determination to avoid all defecationall defecation

• With time this becomes an automatic With time this becomes an automatic reactionreaction

• The rectal wall stretches and fecal soiling The rectal wall stretches and fecal soiling may occurmay occur

• After several days, irritability, abdominal After several days, irritability, abdominal distention, cramps, and decreased oral distention, cramps, and decreased oral intake may resultintake may result

• 1 yr prospective study of 2144 1 yr prospective study of 2144 children <5 yrs of age referred to children <5 yrs of age referred to outpatient clinic with constipationoutpatient clinic with constipation– 48% had history of hard stool, all but 48% had history of hard stool, all but

three received laxativesthree received laxatives•50% were treated with suppositories, 50% were treated with suppositories,

enemas or combination of bothenemas or combination of both

• Lack of structure in management of Lack of structure in management of constipation in preschool childrenconstipation in preschool children

• Time lapse between onset of Time lapse between onset of symptoms and referral to a specialistsymptoms and referral to a specialist

• Reluctance to increase laxative Reluctance to increase laxative treatmenttreatment

• Failure to address parents’ anxietiesFailure to address parents’ anxieties

Contributing factorsContributing factors

• Emotional distressEmotional distress

• Family distressFamily distress

• IllnessIllness

• Dietary switch from human to cow’s milkDietary switch from human to cow’s milk

• Lack of dietary fiberLack of dietary fiber

• Changes in EnvironmentChanges in Environment

• TravelTravel

• DrugsDrugs

Drugs that can cause Drugs that can cause constipationconstipation

• Analgesics (NSAIDS)Analgesics (NSAIDS)

• AnticholinergicsAnticholinergics

• Calcium Channel BlockersCalcium Channel Blockers

• Iron SupplementsIron Supplements

• Lead PoisoningLead Poisoning

• OpiatesOpiates

• Tricyclic antidepressantsTricyclic antidepressants

EncopresisEncopresis

• Involuntary defecation of Involuntary defecation of psychogenic originpsychogenic origin

• More common in malesMore common in males• Usually appears in children over 4 yrs Usually appears in children over 4 yrs

of age, avg age 4 yrs 7 mosof age, avg age 4 yrs 7 mos• Associated with recurrent uti and Associated with recurrent uti and

enuresis (disappear when intestinal enuresis (disappear when intestinal problems corrected)problems corrected)

EncopresisEncopresis

• Need more rigorous Need more rigorous therapeutic program therapeutic program for treatmentfor treatment– Initial objective is to Initial objective is to

keep the rectum empty keep the rectum empty in order to diminish its in order to diminish its size, increase rectal size, increase rectal sensibility to distention sensibility to distention and avoid encopresisand avoid encopresis

EncopresisEncopresis

• First step: rectal disimpactionFirst step: rectal disimpaction– Hypertonic phosphate enemas or bissacodyl Hypertonic phosphate enemas or bissacodyl

suppositories until evacuation without solid fecessuppositories until evacuation without solid feces• Second step: prevent reaccumulation of Second step: prevent reaccumulation of

retained feces and prevent reoccurrence of retained feces and prevent reoccurrence of encopresisencopresis– Osmotic laxatives or stimulants or mineral oil in Osmotic laxatives or stimulants or mineral oil in

high doseshigh doses• Develop a regular defecation scheduleDevelop a regular defecation schedule

– Take advantage of the gastrocolic reflex (5-15 Take advantage of the gastrocolic reflex (5-15 mins)mins)

• Manometric feedback?Manometric feedback?

TreatmentTreatment

• Dietary changesDietary changes

• Bulk forming agentsBulk forming agents

• Lubricants Lubricants

• Hyperosmolar agents Hyperosmolar agents

Dietary managementDietary management

• High fiber dietHigh fiber diet– Age + 5= grams of fiber per dayAge + 5= grams of fiber per day– Increase amount gradually to prevent Increase amount gradually to prevent

side effectsside effects– Fruits, breads and cerealsFruits, breads and cereals

• Fluid intakeFluid intake

Bulk-forming agents Bulk-forming agents

• Increase bulk of the nonabsorbable Increase bulk of the nonabsorbable portion of the intestinal contents to portion of the intestinal contents to increase the stimulus for peristalsis increase the stimulus for peristalsis mimicking the normal course of mimicking the normal course of defecationdefecation

Stimulant agentsStimulant agents

• Increase the irritability of the Increase the irritability of the intestinal muscle so that it responds intestinal muscle so that it responds more to distentionmore to distention

LubricantsLubricants

• Soften the feces and ease defecationSoften the feces and ease defecation

• Do not initiate defecationDo not initiate defecation

Hyperosmolar AgentsHyperosmolar Agents

• Increase the intestinal volume via an Increase the intestinal volume via an osmotic effectosmotic effect

Treatment Treatment • Simple ConstipationSimple Constipation

– Dietary measures, bowel habit trainingDietary measures, bowel habit training• Prolonged ConstipationProlonged Constipation

– As aboveAs above– Low dose mineral oil, senna or lactuloseLow dose mineral oil, senna or lactulose

• Chronic Constipation with Mega rectum and Chronic Constipation with Mega rectum and encopresisencopresis– Fecal disimpaction with phosphate enemas or Fecal disimpaction with phosphate enemas or

bisacodyl suppositoriesbisacodyl suppositories– Dietary measures, bowel habit training, high Dietary measures, bowel habit training, high

dose mineral oil, lactulose or miralax, dose mineral oil, lactulose or miralax, psychological supportpsychological support

• Voluntary fecal incontinenceVoluntary fecal incontinence– Psychologic evaluation and treatmentPsychologic evaluation and treatment

Stepwise approach to Stepwise approach to treatmenttreatment

• Step one: Diet and regular bowel Step one: Diet and regular bowel habitshabits

• Step two: Produce a natural course Step two: Produce a natural course of defecation with bulk-forming of defecation with bulk-forming agents or ease defecation with stool agents or ease defecation with stool softenerssofteners

• Step three: Stimulant laxatives for Step three: Stimulant laxatives for resistant casesresistant cases

Route of administrationRoute of administration

• First step should be oral agents; First step should be oral agents; reserve rectal route for fecal reserve rectal route for fecal impactionimpaction

Treatment of infantsTreatment of infants

• Increased intake of fluids, particularly Increased intake of fluids, particularly juices with sorbitol (prune, pear and juices with sorbitol (prune, pear and apple)apple)

• Lactulose, Karo syrup, sorbitol can be Lactulose, Karo syrup, sorbitol can be usedused

• Glycerin suppositoriesGlycerin suppositories• Avoid mineral oil in very young Avoid mineral oil in very young

– Lipoid pneumoniaLipoid pneumonia

Pediatric dosages of Pediatric dosages of laxativeslaxatives

Behavioral ModificationsBehavioral Modifications

• Regular toilet habitsRegular toilet habits– Unhurried time on the toilet after mealsUnhurried time on the toilet after meals

• Diaries of stool frequency combined with a Diaries of stool frequency combined with a reward systemreward system

• Referral to mental health provider for Referral to mental health provider for behavior modification behavior modification

• Requires family that is well organized, can Requires family that is well organized, can complete time consuming interventions complete time consuming interventions and is sufficiently patient to endure and is sufficiently patient to endure gradual improvements and relapsesgradual improvements and relapses

Maintenance therapyMaintenance therapy

• Mineral oil, sorbitol or MOMMineral oil, sorbitol or MOM– 1-3 cc/kg/day1-3 cc/kg/day

• PEG 3350 2 tsp/ 8 oz liquid qd-tidPEG 3350 2 tsp/ 8 oz liquid qd-tid• May be necessary for several monthsMay be necessary for several months• Only consider discontinuation when Only consider discontinuation when

the child has been having regular the child has been having regular bowel movements without difficultybowel movements without difficulty

• Relapses are common!Relapses are common!

PreventionPrevention

• Counsel parents on normal Counsel parents on normal defecation habits defecation habits

• Introduce good dietary habitsIntroduce good dietary habits– Adequate intake of liquids with only Adequate intake of liquids with only

moderate consumption of milk moderate consumption of milk – Balanced fiber-rich dietBalanced fiber-rich diet

ReferencesReferences

• Lowe, Julie and Bruce Parks. “Movers and Shakers: Lowe, Julie and Bruce Parks. “Movers and Shakers: A clinician’s guide to laxatives.” Pediatric Annals. A clinician’s guide to laxatives.” Pediatric Annals. 1999 (307-310).1999 (307-310).

• Weaver, Lawrence. “Constipation: Diagnosis and Weaver, Lawrence. “Constipation: Diagnosis and treatment.” Seminars in Pediatric Gastroenterology treatment.” Seminars in Pediatric Gastroenterology and Nutrition. Vol 3: Number 4. 1992. (1-14).and Nutrition. Vol 3: Number 4. 1992. (1-14).

• Baker, Susan et al. “Constipation in Infants and Baker, Susan et al. “Constipation in Infants and Children: Evaluation and Treatment.” Journal of Children: Evaluation and Treatment.” Journal of Pediatric Gastroenterology and Nutrition. 29:612-Pediatric Gastroenterology and Nutrition. 29:612-626. 626.

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