FAILURE TO THRIVE

BYDR.RANDA AL-GHANEMPEDIATRIC GI CONSULTANTConstipationDEFINITIONINFREQUENT BOWEL MOVEMENTS (TYPICALLY THREE TIMES OR FEWER PER WEEK)DIFFICULTY DURING DEFECATION (STRAINING DURING MORE THAN 25% OF BOWEL MOVEMENTS OR A SUBJECTIVE SENSATION OF HARD STOOLS), ORTHE SENSATION OF INCOMPLETE BOWEL EVACUATION.

CONSTIPATION IN CHILDREN USUALLY OCCURS AT THREE DISTINCT POINTS IN TIME: AFTER STARTING FORMULA OR PROCESSED FOODS (WHILE AN INFANT), DURINGTOILET TRAINING IN TODDLERHOOD, AND SOON AFTER STARTING SCHOOL.AFTER BIRTH, MOST INFANTS PASS 4-5 SOFT LIQUID BOWEL MOVEMENTS (BM) A DAY.BREAST-FED INFANTS USUALLY TEND TO HAVE MORE BM COMPARED TOFORMULA-FED INFANTS.

SOME BREAST-FED INFANTS HAVE A BM AFTER EACH FEED, WHEREAS OTHERS HAVE ONLY ONE BM EVERY 23 DAYS.

INFANTS WHO ARE BREAST-FED RARELY DEVELOP CONSTIPATION.

BY THE AGE OF TWO YEARS, A CHILD WILL USUALLY HAVE 12 BOWEL MOVEMENTS PER DAY AND BY FOUR YEARS OF AGE, A CHILD WILL HAVE ONE BOWEL MOVEMENT PER DAY.

CAUSESTHE CAUSES OF CONSTIPATION CAN BE DIVIDED INTOCONGENITAL, PRIMARY, AND SECONDARY. THE MOST COMMON CAUSE IS PRIMARY AND NOT LIFE-THREATENING.IN THE ELDERLY, CAUSES INCLUDE: INSUFFICIENT DIETARY FIBER INTAKE, INADEQUATE FLUID INTAKE, DECREASED PHYSICAL ACTIVITY, SIDE EFFECTS OF MEDICATIONS,HYPOTHYROIDISM, AND OBSTRUCTION BYCOLORECTAL CANCER.FEMALES ARE MORE OFTEN AFFECTED THAN MALES.

PRIMARYPRIMARY OR FUNCTIONAL CONSTIPATION IS ONGOING SYMPTOMS FOR GREATER THAN SIX MONTHS NOT DUE TO ANY UNDERLYING CAUSE SUCH AS MEDICATIONSIDE EFFECTSOR AN UNDERLYING MEDICAL CONDITION.IT IS NOT ASSOCIATED WITH ABDOMINAL PAIN, THUS DISTINGUISHING IT FROMIRRITABLE BOWEL SYNDROME.IT IS THE MOST COMMON CAUSE OF CONSTIPATION.DIETCONSTIPATION CAN BE CAUSED OR EXACERBATED BY A LOW FIBER DIET, LOW LIQUID INTAKE, OR DIETING. MEDICATIONMANY MEDICATIONS HAVE CONSTIPATION AS A SIDE EFFECT. SOME INCLUDE (BUT ARE NOT LIMITED TO);OPIOIDSCOMMON PAIN KILLERS ,DIURETICS , ANTIDEPRESSANTS ,ANTIHISTAMINES ,ANTI PASMODICS ,ANTICONVULSANTS, AND ALUMINUMANTACIDS.

METABOLIC AND MUSCULARMETABOLIC AND ENDOCRINE PROBLEMS WHICH MAY LEAD TO CONSTIPATION INCLUDE: HYPERCALCEMIA,HYPOTHYROIDISM,DIABETES MELLITUS,CYSTIC FIBROSIS, ANDCELIAC DISEASE.CONSTIPATION IS ALSO COMMON IN INDIVIDUALS WITH MUSCULAR AND MYOTONIC DYSTROPHY.

STRUCTURAL AND FUNCTIONAL ABNORMALITIESCONSTIPATION HAS A NUMBER OF STRUCTURAL (MECHANICAL, MORPHOLOGICAL, ANATOMICAL) CAUSES, INCLUDING: SPINAL CORD LESIONS ,ANAL FISSURES,AND PROCTITIS.CONSTIPATION ALSO HAS FUNCTIONAL (NEUROLOGICAL) CAUSES, INCLUDINGANISMUS,DESCENDING PERINEUM SYNDROME, AND HIRSCHSPRUNG'S DISEASE.IN INFANTS, HIRSCHSPRUNG'S DISEASE IS THE MOST COMMON MEDICAL DISORDER ASSOCIATED WITH CONSTIPATION. ANISMUS OCCURS IN A SMALL MINORITY OF PERSONS WITH CHRONIC CONSTIPATION OR OBSTRUCTED DEFECATION.

PSYCHOLOGICALVOLUNTARY WITHHOLDING OF THE STOOL IS A COMMON CAUSE OF CONSTIPATION. THE CHOICE TO WITHHOLD CAN BE DUE TO FACTORS SUCH AS FEAR OF PAIN, FEAR OF PUBLIC RESTROOMS, OR LAZINESS.WHEN A CHILD HOLDS IN THE STOOL A COMBINATION OF ENCOURAGEMENT,FLUIDS,FIBER, ANDLAXATIVESMAY BE USEFUL TO OVERCOME THE PROBLEM.

DIAGNOSISTHE DIAGNOSIS IS ESSENTIALLY MADE FROM THE PATIENT'S OR PARENTS DESCRIPTION OF THE SYMPTOMS ( INCLUDE BLOATING,DISTENSION, ABDOMINAL PAIN, HEADACHES, A FEELING OF FATIGUE AND NERVOUS EXHAUSTION, OR A SENSE OF INCOMPLETE EMPTYING) AND NUTRETIONAL HISTORY.

DURINGPHYSICAL EXAMINATION,SCYBALA(MANUALLY PALPABLE LUMPS OF STOOL) MAY BE DETECTED ON PALPATION OF THE ABDOMEN.

DIAGNOSIS

RECTAL EXAMINATIONGIVES AN IMPRESSION OF THE ANAL SPHINCTERTONE AND WHETHER THE LOWER RECTUM CONTAINS ANY FECES OR NOT AND FOR POLYPS.

ACOLONOSCOPE AND X-RAYSOF THE ABDOMEN, GENERALLY ONLY PERFORMED IF BOWEL OBSTRUCTION IS SUSPECTED.

CRITERIATHE ROME II CRITERIA FOR CONSTIPATION REQUIRE AT LEAST TWO OF THE FOLLOWING SYMPTOMS FOR 12 WEEKS OR MORE OVER THE PERIOD OF A YEAR: STRAINING WITH MORE THAN ONE-FOURTH OFDEFECATIONSHARDSTOOLWITH MORE THAN ONE-FOURTH OFDEFECATIONSFEELING OF INCOMPLETE EVACUATION WITH MORE THAN ONE-FOURTH OFDEFECATIONSSENSATION OFANORECTALOBSTRUCTION WITH MORE THAN ONE-FOURTH OFDEFECATIONSMANUAL MANEUVERS TO FACILITATE MORE THAN ONE-FOURTH OFDEFECATIONSFEWER THAN THREEBOWELMOVEMENTS PER WEEKINSUFFICIENT CRITERIA FORIRRITABLE BOWEL SYNDROME

PREVENTIONCONSTIPATION IS USUALLY EASIER TO PREVENT THAN TO TREAT. FOLLOWING THE RELIEF OF CONSTIPATION.

MAINTENANCE WITH ADEQUATE EXERCISE, FLUID INTAKE, AND HIGH FIBER DIET IS RECOMMENDED.

CHILDREN BENEFIT FROM SCHEDULED TOILET BREAKS, ONCE EARLY IN THE MORNING AND 30 MINUTES AFTER MEALS.

TREATMENTTHE MAIN TREATMENT OF CONSTIPATION INVOLVES THE INCREASED INTAKE OF WATER AND FIBER.THE ROUTINE USE OF LAXATIVES IS DISCOURAGED, AS HAVING BOWEL MOVEMENTS MAY COME TO BE DEPENDENT UPON THEIR USE.ENEMASCAN BE USED TO PROVIDE A FORM OF MECHANICAL STIMULATION. HOWEVER, ENEMAS ARE GENERALLY USEFUL ONLY FOR STOOL IN THE RECTUM, NOT IN THE INTESTINAL TRACT.

LAXATIVES- LACTULOSE ANDMILK OF MAGNESIA HAVE BEEN COMPARED WITHPOLYETHYLENE GLYCOL(PEG) IN CHILDREN. - ALL HAD SIMILAR SIDE EFFECTS, BUT PEG WAS MORE EFFECTIVE AT TREATING CONSTIPATION.OSMOTIC LAXATIVES ARE RECOMMENDED OVER STIMULANT LAXATIVES.

PHYSICAL INTERVENTION- CONSTIPATION THAT RESISTS THE ABOVE MEASURES MAY REQUIRE PHYSICAL INTERVENTION SUCH AS MANUAL DISIMPACTION (THE PHYSICAL REMOVAL OF IMPACTED STOOL USING THE HANDS)

PROGNOSIS- COMPLICATIONS THAT CAN ARISE FROM CONSTIPATION INCLUDE ANAL FISSURES,RECTAL PROLAPSE, ANDFECAL IMPACTION.- STRAINING TO PASS STOOL MAY LEAD TOHEMORRHOIDS. - IN LATER STAGES OF CONSTIPATION, THE ABDOMEN MAY BECOME DISTENDED, HARD AND DIFFUSELY TENDER. SEVERE CASES ("FECAL IMPACTION" ORMALIGNANT CONSTIPATION) MAY EXHIBIT SYMPTOMS OF BOWEL OBSTRUCTION (VOMITING, VERY TENDER ABDOMEN) ANDENCOPRESIS, WHERE SOFT STOOL FROM THE SMALL INTESTINE BYPASSES THE MASS OF IMPACTED FECAL MATTER IN THECOLON.HIRSCHSPRUNG`S DISEASEDEFINITION:-DEFECT IN ITESTINAL MOTILITY ASSOCIATED WITH COPLETE ABSENCE OF ENTERIC GANGELIA IN THE INVOLVED SEGMENT OF THE COLON.INCIDENCE: 1:5000 LIVEBIRTHRATIO: 4 MALE : 1 FEMALEASSOCIATED WITH:1-DOWN SYNDROME 2- WAARDENBURG SYNDROME3- KAUFMANN-MC SYNDROME 4- SMITH LEMLI OPTIZ SYNDROME5- GOLDBERG SHPRINZEN SYNDROME 6- ONDINE SYNDROME7- V-U REFLUX AND HYDROURETERS DIVERTICULUMN OF BLADDER8-CEREBRAL A-V MALFORMATION 9- MICROCEPHALY10- MYELOMENINGOCELE 11- MEN (TYPE 2)

BARIUM ENEMA EXAMINATION SHOWING RECTO-SIGMOID HIRSCHSPRUNG'S DISEASE

CLINICAL FINDING:2/3 OF CASES DIAGNOSED AT 3 MONTHSVERY SMALL NUMBERS OF PATIENT DIAGNOSED AFTER 5 YEARS

1ST WEEK OF LIFE:PATIENT IS AVERAGE OF WEIGHT.FAIL TO PASS MECONIUMRELUCTANT TO FEEDBILIOUS VOMITINGABDOMINAL DISTENSIONGRUNTINGINFANCY:PRESENT WITH :CONSTIPATIONABDOMINAL DISTENSIONVOMITING

CHILDHOOD:PRESENT WITH CONSTIPATION OFFENSIVE RIBBON-LIKE STOOLABDOMINAL DISTENSIONHYPOCHROMIC ANEMIAHYPOPROTEINEMIAENCOPORESISDIAGNOSIS:RECTAL EXAM: NARROW, EMPTY RECTUM AND AS THE FINGER IS WITHDRAWN.X-RAY:DESTENSION OF GAS AND ABSENCE OF GAS IN PELVISRECTAL BIOPSY: PROCEDURE OF CHOISE.MANOMETRIC STUDY: RECORDING INTERNAL AND EXTERNAL RECTAL PRESSURE.

TREATMENT:-CORRECT DEHYDRATION.CORRECT ACID-BASE PROBLEMSPARENTERAL FLUIDSCORRECT HYPOALBUMINEMIA OR ANY SHOCKRECTAL IRRIGATION BY NORMAL SALINE SOLUTIONSURGERY:COLOSTOMY.

DEFFERENTIATE BETWEEN FUNCTIONAL CONSTIPATION AND HIRSCHSPRUNGFUNCTIONAL CONSTIPATIONHIRSCHSPRUNG DISEASEHISTORYAFTER 2 YEARSAT BIRTHENCOPRESISCOMMONVERY RAREF.T.TUNCOMMONPOSSIBLEENTEROCOLITISNONEPOSSIBLEABDOMINAL PAINCOMMONCOMMONEXAMINATIONABDOMINAL DISTENSIONRARECOMMONPOOR WEIGHT GAINRARECOMMONANAL TONENORMALNORMALRECTAL EXAMSTOOL IN AMPULAAMPULA EMPTYLABANORECTAL MANOMETRYDISTENSION OF THE RECTUM CAUSES RELAXATION OF UNIT SPHINCTERNO SPHINCTER OR PARADOXIAL RELAXATION OR INCREASE IN PRESSURERECTAL BIOPSYNORMALNO GANGELIA CELLBA ENEMAMASSIVE AMOUNT OF STOOLNO TRANSITIONAL ZONEINCREASE ACETYL CHOLENSTRASE STAININGTRANSITION ZONE, DELAYED EVACUATIONTHANK YOU