Constipation&incontinence

Constipation & Incontinencein Children

Mohamed El-Debeiky

MSc, MD, MRCSEd

Causes

• HSD

• ARM

• Idiopathic constipation

Hirschsprung’s Disease

• It is a form of chronic intestinal obstruction caused by congenital absence of ganglion cells in both the intermuscular and submucosal plexuses.

Pathologic Anatomy

• Distal Narrow Segment: Aganglionic

• Proximal Dilated Segment: Ganglionic.

• Transitional Zone: Hypoganglionic.

Extent of Aganglionosis• Short segment (75%):

Rectosigmoid.

• Long segment (20%): Descending colon.

• Total Colonic (5%): Colon and parts of small intestine.

Clinical Picture

• Age: 50% neonates, 45% up to 2 yrs,

5% > 2yrs.• Failure to pass

meconium within 48hrs

• Abdominal distension.• Constipation.

Clinical Picture

• Vomiting.

• Diarrhea (enterocolitis).

• Perforation.

• Rectal exmaination.

Differential Diagnosis

• Meconium plug, Meconium ileus, Stenotic anus.

• NEC, Sepsis, Hypothyroidism.

• Functional constipation.

• Neuronal intestinal dysplasia (NID).

Diagnosis

• Plain X-ray Abdomen.

• Barium Enema (unprepared).

• Ano-rectal manometry.

• Rectal Biopsy.

Surgical Treatment ForHirschsprung’s Disease

• Three Stages: Outdated.• Two Stages: Standard (colostomy, pull through).• One Stage: Selected cases.

Age for definitive Pull through

• 9 months: Out dated.

• 6 months: Standard.

• Neonates: Selected cases.

Type of Surgery

• Abdomino-perineal pull through.

• Trans anal pull through.

ANORECTAL MALFORMATIONS

- 1 : 4 – 5000 newborns

- Males > Females

TYPES OF DEFECTS ( classification )

MALE DEFECTS

1. Low Defects : Perineal fistulaMedian raphe fistula

Bucket handle malformationAnal stenosis Anal membrane

2. Rectourethral bulbar fistula

3. Rectourethral prostatic fistula

4. Rectovesical ( bladder neck ) fistula

5. Imperforate anus without fistula

6. Rectal atresia and stenosis

Median raphe fistula

Rectourethral fistula

FEMALE DEFECTS

1. Low defect : Perineal fistula

2. Vestibular fistula

3. Vaginal fistula

4. Imperforate anus without fistula

5. Rectal atresia and stenosis

6. Persistent cloaca

Vestibular fistulaVestibular fistula3 orifices

ASSOCIATED DEFECTSASSOCIATED DEFECTS

UrogenitalUrogenital - Most common - Most common - 20 - 20 – 45 %– 45 %- The higher the malformation the higher the incidenceThe higher the malformation the higher the incidence

Sacrum and SpineSacrum and Spine - Sacrum frequently abnormal- Sacrum frequently abnormal deformeddeformed

reduced in numberreduced in number hemisacrumhemisacrum

- Spine frequently shows - Spine frequently shows hemivertebraehemivertebrae

D.D: Functional (Constitutional) Constipation.

• Common complaint: Constipation or incontinence.

• History: Period of normal defecation followed by constipation.

• Age: from infancy to puberty.• Causes: Emotional & stress, chronic

dehydration, anal fissure, drugs (opiates & anticholinergic), hypothyroidism.

D.D:Functional ConstipationDiagnosis

• History: Personal, Family.

• Examination: Abdomen,PR

• Plain x-ray• Barium Enema• Rectal Biopsy ?

Contrast Eenema

D.D:Functional ConstipationTreatment

• Initial evacuation of retained stools by enemas.

• Regular evacuation of rectum by suppositaries.

• Stool softners.• Treatment of anal fissurs.• Dietary.• Toilet training.

Stimulant laxatives

• Senna

• Biascodyl

• Glycerine

• MoM

Surgery

CONCLUSION

• Early detection, proper diagnosis & management of constipation in children gives excellent results.

• Hirschsprung’s disease should be suspected in cases of constipation resisting ordinary treatment.

THANK

YOU