Melanie Gissen, M.D. If you got to go, go now. – Bob Dylan
LEARNING OBJECTIVES:
1. Recognition of and appropriate intervention for common presentations of constipation in infancy, childhood and adolescence
2. Familiarity with pharmacologic, dietary and behavioral interventions for constipation
3. Recognition of some of the more common organic causes of constipation
INFANT DYSCHEZIA:
CASE #1: A three month old turns red, cries, and seems to be in pain when trying to pass a stool. She has one or two soft stools a day. The baby is feeding and growing well, has no medical issues, and her physical exam is normal.
What is the definition of infant dyschezia?
FUNCTIONAL CONSTIPATION:
CASE #2: A two year old has a bowel movement about twice a week, and his stools are extremely hard. He cries when he passes a stool and mother has occasionally noted a small amount of bright red blood when she cleans him. He appears well nourished but his diet consists of eight bottles of cow’s milk a day, rice and chicken. He is a picky eater who won’t eat beans and dislikes all fruits and vegetables.
What is the definition of functional constipation?:
FUNCTIONAL FECAL RETENTION:
CASE #3A: Five year old Jose had been having normal BM’s until about two years of age, when after passing a very hard stool, he became “afraid of pooping”. He started stiffening and crossing his legs when he felt the urge to have a BM. At first his mother thought he was trying to push the stool out but then realized he was trying to hold it in. He began having less frequent BM’s and now moves his bowels about once a week. Sometimes there is stool soiling his underwear.
CASE #3B: A mother brings in her seven year old son because at a recent family gathering he had an episode of stool leakage, which greatly embarrassed her. She believes this was intentional and she punished him after the event. History reveals that for a long time his pattern has been to pass a large stool about once or twice a week that is described as filling the toilet. At his school students are discouraged by staff from using the toilets (or there are no doors on the stalls, or there is no toilet paper available). Two years ago his sister was born at 24 weeks gestation and mother has had to spend a lot of time at the hospital with her.
What is the definition of functional fecal retention?:
CONSTIPATION IN ADOLECENTS:
CASE #4: An 18 year old female is concerned because she has seen some blood on the toilet paper after having a bowel movement, and feels a little ball outside her rectum. She has to push very hard to pass a stool. She is taking no medications, and has no other medical issues. You review her diet, which is low in fiber and fluids. On exam, you note a hemorrhoid.
How does constipation present in adolescence?:
HIRSCHPRUNG’S DISEASE:
CASE #5: A six month old infant male who is a recent immigrant from the DR presents with constipation “since birth”. He has always been difficult to feed despite frequent formula changes. He vomits a lot and was prescribed zantac for suspected GERD after presenting to the ER. On exam you note that his abdomen is distended and his weight plots at the 5th percentile.
What features of this case raise suspicion for Hirschprung’s Disease (aganglionosis)?
WHAT IS THE TREATMENT OF CONSTIPATION?
WHO SHOULD BE REFERRED TO A SUBSPECIALIST?
WHAT IS THE DIFFERENTIAL DIAGNOSIS OF CONSTIPATION?
Attachments:
Constipation Formulary
(Anti)Constipation Diet
References:
1. Youssef NN, Di Lorenzo C: Childhood Constipation, J Clin Gastroenterol 2001:33(3):199-205
2. Evaluation and treatment of constipation in infants and children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroentol Nutr 2006 Sep 43(3):e1-13
