Prof.DR.Subijanto,MS,dr,SpA(K) DR.Reza Ranuh,dr,SpA(K) Alpha Fardah,dr,SpA Andy Darma, dr, SpA Dept.

of Child Health Soetomo Hospital Medical Faculty Airlangga University Kuliah Semester VI - 2010

3% of all general pediatric visits 10-25% cases in pediatric gastroenetrology Prevalence : 0.3% - 28% ( young age, > functional constipation ) Male : 70.3% - female: 29.63% ( Pitono Soeparto 1991 ) Chronic constipation : 15.05% Hirschsprungs ; 39.78% megacolon with normal hystopatology 35.48% : normal radiographs 2.15% : intestinal hypomotility

Delay or difficulty in defecation : > 2 weeks Causing significan distress 90% functional constipation 3% of all pediatrict clinical practice 10 25% pediatric gastroenterology

Functional/Non-organic (>95%) Intestinal

Pseudo-obstruction Hirschprung disease Anal stricture/stenosis Anterior dislocation of the anus Meconium ileus equivalent (CF) Celiac disease

Metabolic

Drugs

Hypothyroidism Hypopotasium Hypercalcemia Dehydration

Neuromuscular

Narcotics Antidepressants Lead Infant botulism Spinal cord lesion

Meconeum first 24 hours 87% Meconeum first 48 hours 99% Infant week I : 1 9 x/day Infant week II : 1 7 x/day 37 mo : complete bowel

control

Pre-school age : 3 x/d ; 3 x/week. Normal consistency. Normal size.

 Temporary reflex relaxation of the IAE (RAIR) mediated by the autonomic nervous system

Defecation convenient

Diaphragms and abdominal muscle contraction Increased intrarectal pressure Puborectalis muscle relaxation EAS relaxation Mediataed by the voluntary nervous system Puborectalis muscle contraction Evacuation of stools

Stool in contact with sensitive receptors in anal canal

Sigmoid contraction

Stool in rectum Rectal distension

Simultaneous contraction of EAE giving time to decide if circumstances are are appropriate for defecation

Defecation inconvenient

EAE contraction Accommodation of rectum to its contents Mediated by the voluntary nervous system

Defecation postponed

Painful defecation

Fear of defecation

A faecal mass accumulates in rectum

Functional megarectum Loss of rectal sensitivity With-holding behaviour Pelvic floor muscle fatigue Anal sphincter incontinence Overflow incontinence

Healthy infants ; < 6 months Childs learning process Significant discomfort and excessive straining associated with passing soft stools Resolve spontaneously few weeks Related to a failure to coordinate increased intraabdominal pressure with pelvic floor relaxation No intervention rectal stimulation should be avoided to prevent artificial sensory experiences Unnecessary laxatives

Intestinal neural displasia Visceral myopathies Visceral neurophaties

Confirm Diagnosis with studies of colonic function :

Radio-opaque marker studies Scintigraphy

Colonic manometry

Schappi MG, et al. Gut. 2003 ; 52(5) : 275-5

> 95%

Non - organic

The incidence : 1 in 5,000 live births The most cause of lower intestinal obstruction in newborn 3% of children and toddler with severe refractory constipation A congenital condition characterized by the absence of ganglion cells in the submucosal (Meissners) and myenteric (Auerbachs) plexus of the distal small bowel The length of intestine involved varies Functional obstruction results

Should be suspected in:

- any infant who doesnt pass
meconium within the first 24 hours of life

- newborn intestinal obstruction

- constipation / chronic abdominal distention

in the first year of life

History and physical examination

Perianal area, spine, reflexes, distal extremities, digital rectal examination

Constipation early of life : serious congenital disorder

Constipation first year of life : 40% functional constipation

Occult blood in stool associated abdominal pain, failure to thrive, and intermittent diarrhea Positive occult blood test : enterocolitis, intestinal inflammation. Others lab : hypercalcemia, hypothyroidism and coeliac disease Sweat test : delayed meconium suspected cystic fibrosis

Not indicated in uncomplicated constipation Abdominal radiograph : detection of faecal impaction (obese child)

The absence of gangglion cells

Rectal biopsy

Functional constipation

Hirschcprungs disease

Starts at birth Fecal incontinence Rectal fecal mass Retentive posturing Passage of large stool

no often yes yes often

yes rare no no rare

Anal fissures

common

rare

 Child

& family education Treat fecal impaction Maintenance trerapy ( stool softeners preferred to stimulant laxatives) Toilet training advise

Explanation normal defecation mechanism Pathogenesis of functional constipation Toilet training Positive and supportive attitude of parents Explanation chronicity and possible recurrences

Disimpaction Maintenance treatment

Oral : > 2 years : - polyethylene glycol - mineral oil - Lactulose or sorbitol Rectal : - Glycerine supp - Physiological enema _ Contraindicated : soap supp, tap water, or magnesium enema

Diet : - increased intake of fluid - reduce dairy products - natural fibre ingestion Behavioural modification : - Regular toilet habits - Unhurried time after meals - Diaries of stool frequency - Reward system Medication : - Continuous for 3-6 months - Lubricants and osmotic agents

Follow-up 1-2 weeks ; 1 month and every 3, 6 months Toilet training evaluation Gradual weaning of medication after months Maintenance treatment in 6 24 months 30% of children followed beyond puberty continue to have constipation and/or fecal incontinence Adult study (n=63) : 22 patients had megarectum. Almost all had fecal incontinence and 90% were on laxative since childhood 30% persistent constipation in adolescent (constipation and soiling) Relapse in 4 years

Functional constipation is common Children with chronic intractable constipation who do not improve with standard medical therapy may need anal sphincter & colon function evaluation Colon motility studies help in surgical decision making & help predict the outcome of cecostomy Anorectal and colon manometry also helps in evaluating defecation problem following Hirschsprungs surgery