Constipation & Diarrhea March 4, 2010. Objectives 1. Learn an approach to treating constipation in the Emergency Room and on discharge 2. Discuss when.

Constipation & DiarrheaMarch 4, 2010

Objectives

1. Learn an approach to treating constipation in the Emergency Room and on discharge

2. Discuss when “constipation” needs further workup

3. Diarrhea-discuss the common and important ED presentations

True or False

1) Correction of constipation has been shown to diminish enuresis

2) Correction of constipation has been shown to decrease the frequency of UTI’s

3) Fecal soiling is associated with severe functional constipation

4) Constipation can be a cause of rectal prolapse

5) On digital rectal exam, no stool in the rectal vault is consistent with functional constipation

True or False

6) Vomiting can be a sign of Hirshsprung’s

7) Vomiting can be a sign of functional constipation

8) Celiac disease can present as constipation

9) Constipation is the first symptom of botulism

Few more quick facts

1) When is the 1st stool of a neonate normally passed?

2) Which chemotherapy agent causes constipation?

Definitions

Constipation

Functional Constipation

Definitions

ConstipationDelay or difficulty in defecation, present for

>2 weeks

Functional Constipation Constipation without objective evidence of a

pathologic condition

Case 1

2 month baby, term, formula fed Having 4-5 bowel movements/week Grandma thinks something is seriously

wrong because her other grandchild has 4-5 bowel movements/day

What do you do?

Normal Defecation Pattern


NASPGHAN clinical practice guidelines



Approach to Constipation

What is your approach???


Are there any red flags?


Red flagsFeverEmesisBloody diarrheaFTTAnal stenosisTight empty rectumDelayed passage of meconium

If yes….need to investigate further


No red flags=functional constipation Is there fecal impaction?

Yes: disimpact Oral or rectal meds Usually 2-3 days required

No: Treat as outpatient Education, diet, oral meds

Approach to constipation

Treatment effectiveYes: maintence therapy 4-6 monthsNo: Bloodwork

T4, TSH Celiac screen Lead Calcium

If above workup is negative, and child still constipated, refer to GI

But may want to refer for sweat chloride & rectal bx

What about abdominal x-rays?

Not needed if rectal exam reveals large amounts of stoolSens & PPV >80%

If child is obese or refuses the rectal exam, the AXR is reliable in determining fecal retention

If used in combination with DREsens 92% & PPV 94%


Case 2

1 month asian male, term, with 12h hx of constipation Prior to presentation, had had 4-5 BM/day Breastfed, feeding less well at last 2 feeds No emesis Had passed meconium within first 24h Neonatal screen Neg for CF and hypothyroid O/E:

alert, slightly fussy, vitals stable distended abdo, +BS No anal fissure Palpable firm stool in rectum

Case 2

AXR

Case 2

AXR

Case 2

Glycerin supp-resulted in dry, crumbly stool in diaper

Attempted enema-came out immediately Manual disimpaction-able to remove dry hard

stool, with overflow liquid seepage After disimpaction, fed well, abdomen softer Arranged for F/U in Urgent Peds for further W/U

(hirshsprung, CF, hypothyroid)

Case 2

Returned to ED the following afternoon Tachypnic Repeat AXR

Case 2

Case 2

Intubated due to respiratory distress Went up to OR for laparotomy…..with pre-op

suspicion of volvulus

Post op dx: Inspissated stool

Workup all negative Sweat chloride, Hirshsprung’s, thyroid

Case 2: Take home message

Be cautious in diagnosing and discharging a 1 month old with constipation!

Case 3

3 month male with distended abdomen & poor feeding

No emesis Passing stool 2-3 times/day Febrile in ED (38.8) What do you want to do? NB question on history: is the stool liquid? (ie

overflow incontinence) NB finding on exam: tight anal sphincter with no

stool in rectum

Hirshsprung Disease

Most common cause of lower intestinal obstruction in neonates

Rare cause of intractable constipation in toddlers & school age childrenDiagnosed after age 3 in 8-20% of pts

Absence of ganglion cells in the myenteric & submucous plexuses of the distal colonSustained contraction of the aganglionic segment

Hirshsprung Disease

EnterocolitisFever, abdo distension, explosive bloody

diarrheaOccurs at age 2-3 months20% mortalityGreatest risk factor is delayed diagnosis of

Hirshsprung’s

The “don’t want to miss” causes of constipation Hirshsprung Disease Cystic Fibrosis Botulism Hypothyroid Imperforate anus Sacral teratoma Sexual abuse Celiac Disease

Botulism

Initial symptom of botulism is constipation Lethargy and feeding difficulties follow P/E:

Decreased DTR, decreased suck & gag Poorly reactive pupils & Ptosis Oculomotor palsies Facial weakness

Dx: Identify C. botulinum spores & toxin in stool* Tx: Admit! 50-77% require intubation

Baby BIG

Treatment of Constipation

Depends on age If <3 months, should have F/U with a

Pediatrician Consists of

“rescue therapy”maintenance therapy

Acute treatment (>1 year)

Fleet EnemaPediatric 66mL, Adult 133mL

Once >2 yrs, use adult enemaOnset 2-5 minutesSide effects:

Hyperphosphatemia Use with caution in renal failure

Osmotic effect in the small intestine draws water into the gut lumen, produces distension,

promotes peristalsis and evacuation

Maintenance Treatment(>1 year) PEG 3350

Osmotic Laxative Dose 1g/kg/d (Max 17g) Onset in 1-3 days Side effects (minimal):

bloating, cramping, diarrhea, flatulence, nausea

Contraindications GI obstruction, ileus, bowel perforation, toxic colitis,

megacolon

Evidence for PEG 3350

RCT, double blind 100 patients (aged 6 months-15 years) After fecal disimpaction, received either PEG or

Lactulose Primary outcomes:

defecation and encopresis frequency/weeksuccessful treatment after eight weeks

Secondary outcomes:Side effects after 8 weeks

Gut. 2004 Nov;53(11):1590-4.


Success defined as:defecation frequency > 3/weekencopresis < once every 2 weeks

ResultsSuccess was significantly higher in the PEG group

(56%) compared with the lactulose group (29%)PEG 3350 patients reported less abdominal pain,

straining, and pain at defecation than children using lactulose


CONCLUSIONS: PEG 3350 compared with lactulose

provided a higher success rate with fewer side effects

PEG 3350 should be the laxative of first choice in childhood constipation

Treatments to avoid

Mineral oil (if <1 yr, use with caution if <3)Lipoid pneumonia if aspirated

Phosphate enemas (if <1 year)Can use glycerine suppository

Stimulant laxatives (long term)SenekotDulcolax

Case 4

2 year female with 4 day hx of constipation & 8 cm rectal prolapse

Has just started toilet training What are you going to do?

Case 4

Other historyHas 2-3 BM/week with ++strainingFecal soiling presentTerm, passed meconium on day 2 of lifeWas admitted to hospital at 18 months with

pneumonia O/E

Weight & height at 5th percentile

Case 4

Other historyHas 2-3 BM/week with ++strainingFecal soiling presentTerm, passed meconium on day 2 of lifeWas admitted to hospital at 18 months with

pneumonia O/E

Weight & height at 5th percentile

Case 4

What is your immediate treatment?

What is the diagnosis? (top 3)

Case 4

What is your immediate treatment Reduce protrusion (pressure with warm compress) Start pt on stool softeners Surgery in refractive cases

What is the diagnosis? (top 3) Cystic Fibrosis Chronic constipation Meningocoele

True or False

Correction of constipation has been shown to diminish enuresis

TRUE

True or False

Correction of constipation has been shown to decrease the frequency of UTI’s

TRUE

True or False

Fecal soiling is associated with severe functional constipation

TRUE

True or False

Constipation can be a cause of rectal prolapse TRUE but….need to also consider other

etiologies Cystic Fibrosis Meningocoele Enterobius vermicularis (pinworm) Ehlers-Danlos Ulcerative colitis Pertussis

True or False

On digital rectal exam, no stool in the rectal vault is consistent with functional constipation

FALSE

True or False

Vomiting can be a sign of Hirshsprung’s TRUE

True or False

Vomiting can be a sign of functional constipation

FALSE

True or False

Constipation is the first symptom of botulism

TRUE

Quick Facts

When is the 1st stool of a neonate normally passed?

99% pass stool within 24 hours and 100% pass stool within 48 hoursPrems may be a little delayed (76% pass

within 24 hours and 98.8% pass within 48h)

Quick Facts

Which chemotherapy agent causes constipation?

Vincristine

Diarrhea

True or False

1) Salmonella enteritis can be safely treated as an outpatient

2) 40% of infants are colonized with C. diff3) Amoxicillin is responsible for most cases of

pseudomembranous colitis in children4) Switching to a lactose free formula is helpful

during an acute diarrheal illness5) Toddlers diarrhea is the most common cause of

chronic diarrhea in children between the ages of 12-36 months

Diarrhea

Definition

The “not to miss” diagnoses (4)

Diarrhea

Definition Softening in the consistency of the stool with or

without an increase in the number of stools

The not to miss diagnoses (5) Intussusception Pseudomembranous Colitis Hemolytic Uremic Syndrome Appendicits Salmonella enteritis with bacteremia

Diarrhea & Gastroenteritis

Usually no investigations are requiredwatery diarrhea in previously healthy children

Once diarrhea is bloody….do the testsBlood and stool cultures, U/A, CBC, BUN/Cr

Risk factors for bacteremia from gastroFever >5days and child <12 months

Remember to ask about reptiles in the house

HUS Initially mild gastroenteritis Hematochezia Pallor(microangiopathic hemolytic anemia) Purpura (Thrombocytopenia) Hematuria Renal Failure

If parents tell you that the kid hasn’t peed in 24 hours, take them seriously

HUS

Most often in kids <4 years E. coli 0157:H7

Avoid antibiotics in patients with acute enteritis presumed secondary to E.coli 0157

Take home pointDo CBC, Cr, urinalysis in kids with bloody

diarrhea (as well as stool & blood cultures)

Salmonella enteritis

Salmonella gastroenteritis is usually self-limited Fever generally resolves within 48 to 72 hours Diarrhea resolves within 4 to 10 days

BUT…in infants 5-40% will have +blood culture So….children <3 months (some say 1 year) with

symptomatic salmonellosis should be treated with antibiotics until blood cultures are negative Cefotax 100-200mg/kg/d div q6h Ceftriaxone 75mg/kg/d OD

Pseudomembranous colitis

Despite high carrier rates, illness is uncommon in neonates & infants

Abdominal distension, fever and bloody stools are the key physical findings

May occur several weeks after antibiotics Tx:

Discontinue current antibiotic Metronidazole 20-40 mg/kg/d div q6h PO 2nd line Vanco (if really severe, combine flagyl &

vanco) Admit to monitor for toxic megacolon

Case 5

4 month male with daily diarrhea (6x/d) Pretty bad eczema Admitted to hospital at 3 months of age

with pneumonia O/E: weight 4.5kg What are you going to do before sending

this child home?

Case 5

4 month male with daily diarrhea (6x/d) Pretty bad eczema Admitted to hospital at 3 months of age

with pneumonia O/E: weight 4.5kg (Failure to thrive) What are you going to do before sending

this child home?

Case 6

12 month female 5 loose stools/day Mom thinks that occasionally she is bloated Thriving No history of eczema 2 previous URTI’s What do you think the diagnosis is? Mom asks if this could be lactose

intolerance….what do you think?



Toddler’s Diarrhea

Occurs at age 1-3 years History of excessive carbohydrate containing

beverages (specifically sorbital- found in apple, pear & prune juice)

Stools occur during the day (not at night) May contain undigested food particles

Limit sugar containing drinks and increase fat in the diet to 40%

Fluid restriction to <90ml/kg/d

Lactase Deficiency

Congenital lactase deficiency is RARE!<50 cases worldwideSo….when a parent is worried that their infant

is lactose intolerant and this is causing diarrhea….reassure that this is not the cause of their diarrhea (unless their child is #51 in the world)

Secondary Lactose Intolerance

Common Follows small bowel mucosal damage

Ie. Rotavirus, Celiac disease Transient & resolves with mucosal healing Treatment (classically)

Milk free diet or lactose-free formulaBut clinical trials haven't shown a benefit in

acute infectious diarrhea for the majority of infants

Use of Probiotics

Lactobacillus, Bifidobacterium, Saccharomyces

There are RCT’s supporting their use in acute infectious diarrhea and C. diff In rotavirus-diarrhea is briefer and milder

However, therapy is not yet standardized and the most effective organism has not been identified

True or False

Salmonella enteritis can be safely treated as an outpatient

TRUE IF >12 months (possible if >3mo)

True or False

40% of infants are colonized with C. diff TRUE

True or False

Amoxicillin is responsible for most cases of pseudomembranous colitis in children

TRUEBecause of the frequency it is prescribed

True or False

Switching to a lactose free formula is helpful during an acute diarrheal illness

FALSE

True or False

Toddlers diarrhea is the most common cause of chronic diarrhea in children between the ages of 12-36 months

TRUE

Objectives

1. Learn an approach to treating constipation in the Emergency Room and on discharge

2. Discuss when “constipation” needs further workup

3. Diarrhea-discuss the common and important ED presentations

Questions?

Constipation & Diarrhea March 4, 2010. Objectives 1. Learn an approach to treating constipation in the Emergency Room and on discharge 2. Discuss when.

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