CONSTIPATION

Atan Baas Sinuhaji

Department of ChildHealth School of Medicine,University Of Sumatera Utara Medan

CONSTIPATION

FREQ. DEFECATION

- HARD, DRY STOOLS - DIFFICULT/PAIN - INCONTINENCE = SOILING = ENCOPRESIS

FREQUENCY OF DEFECATION NORMAL = 1 X / DAY

ABNORMAL < 1 X / 2 DAYS

SOILING

WITHOUT CONSTIPATION

WITH CONSTIPATION

MENTAL RETARDATION

CLASSIFICATION
1. ACUTE / CHRONIC ( 3 MONTHS ) 2. SEVERITY 3. ORGANIC / FUNCTIONAL 4. PATHOGENESIS 5. ANORECTAL DYSFUNCTION (+)/(-)

RECTAL FILLING

DEFECATION
PROPULTION OF RECTAL CONTENTS

- DISTENTION - CONSTRICTION - RECTAL PRESSURE - URGE TO DEFECATE - STRAINIG - RELAXING THE ANAL SPHINCTER

CONSTIPATION

IMPAIRED RECTAL FILLING

IMPAIRED RECTAL PROPULTION

IMPAIRED RECTAL FILLING

IMPAIRED PERISTALSIS

OBSTRUCTION

DRUGS

HORMONAL

-SPASMOLYTIC -CODEIN HYPOTHYROIDISM

MORBUS HIRSCHSPRUNG

IMPAIRED RECTAL PROPULTION

1. PERISTALSIS 2. OBSTRUCTION 3. SENSATION 4. ANAL SPHINCTER ANAL FISSURE

5. ABNORMALITY OF ABDOMINAL/ PELVIC WALL 6. ABNORMALITY OF AUTONOMIC & CORTICAL CONTROL

CONSEQUENCES

1. VOMITING

2. ABDOMINAL PAIN
3. ABDOMINAL DISTENTION 4. PAIN TO DEFECATE 5. BLOODY STOOLS 6. ANOREXIA ANAL FISSURE

7. ABDOMINAL MASS
8. CHRONIC - PCM

RETENTION OF URINE

- MEGACOLON

MEGACOLON

CONGENITAL

= M. HIRSCHSPRUNG

IDIOPATHIC = ACQUIRED = CHRONIC IDIOPATHIC CONSTIPATION

STOOLS

MEGACOLON

Ganglion (-) Peristalsis Obstruction

External Anal Sphincter INCONTINENTIA ALVI

PARADOXAL DIARRHOEA

BARIUM IN LOOP

MEGACOLON

1. ONSET

IDIOPATHIC= SECUNDER 2-3 YEARS

CONGENITAL 1ST DAY

2. SOILING
3. PARADOXAL DIARRHOEA

(+)
(-)

(-)
(+)

4. PCM
5. ABD. DISTENTION 6. ANAL SPHINCTER

(-)
(+) LOOSE

(+)
(++) TIGHT EMPTY (+)

7. RECTAL AMPULLA FULL 8. ENTEROCOLITIS (-)

9. TREATMENT

MEDICAL

SURGERY

M. HIRSCHSPRUNG

DIAGNOSIS

IRRIGATION
OPERATION FULMINANT ENTEROCOLITIS DEATH

COLOSTOMY DEFINITIVE (6-12 MONTHS)

CHRONIC IDIOPHATIC CONSTIPATION

1. EVACUATION OF FIRM STOOLS (FECAL DISIMPACTION) : MgSO4 IRRIGATION etc MAINTENANCE 1. 2. 3. DIETARY MANIPULATION FIBERS >>>

2.

TAP WATER >>>

TOILET TRAINING DRUGS : a. SPASMOLYTIC (-)

b. LAXANTIA : lactulose polyethylene glycol c. ANAEROB BACTERIAL: metronidazole

FAILURE TO THRIVE
Atan Baas Sinuhaji
Department of ChildHealth School of Medicine,University Of Sumatera Utara Medan

FAILURE TO THRIVE
( FTT ) =1=

GROWTH

Increase in the mass of body tissues

Anthropometric measurement

Body Weight
ABS-BIKA FKUSU

Body Lenght
17

Head Circumference

Development

Skill

ABS-BIKA FKUSU

18

Anthropometric asessment

At the spesific time

Repeated visit

Poor

Poor

Malnutrition

FTT
19

WATERLOW

20

Table 1. WATER LOWS CLASSIFICATION NORMAL WASTED

WEIGHT/ AGE % WEIGHT/ HEIGHT %

STUNTED

100 100

70 70 100

70 100 87

HEIGHT/ AGE %

100

F.T.T
SUBOPTIMAL OF GROWTH

REPEATED VISIT

GENETIC

MALNUTRITION
PSYCHOSOCIAL

FTT

Malnutrition : inadequate nutrients

Malnutrition is the sine qua non of the failure to thrive

ABS-BIKA FKUSU

24

CALORI / NUTRIENTS
Intake Stools Absorption Utilization Basal Metabolism Peripheral Utilization

Growth

BASAL UTILIZATION
MALABSORPTION

IMPAIRED OF PERIPHERAL UTILIZATION

NUTRIENTS
INTAKE

NUTRITION INADEQUATE
MALNUTRITION

Etiology of growth disorders

4. 1. Inadequate intake of calories/nutrients 2. Excessive calories/nutrients losses Vomiting Malabsorption 3. Basal metabolism Fever Hyperthyroidea Hyperkinesia Infection Impaired of peripheral utilization Chronic infection Malignancy Congenital heart diseases Anemia Inborn errors Hormonal

CALORIES / NUTRIENTS

DISEASES

GROWTH

IMMUNITY
ABS-BIKA FKUSU 28

Tabel 2. Complication relative to loss of lean body mass *)

Lean body mass % loss of total Complication (related to lost lean body mass) Impaired immunity, increased infection Decreased healing, weakness, infection Too weak to sit, pressure sores, pneumonia, no healing Associated mortality (%)

10
20 30 40
ABS-BIKA FKUSU

10
30 50

Death usually from pneumonia

29

100

*) assuming no preexisting loss

Immunity Infection (e.g. Measles)

Anorexia Fever Diarrhoea Protein losing enteropathy

ABS-BIKA FKUSU

Malnutrition

Natural (innate)

External : skin, gut motility,etc Internal

Humoral: natural Ab,etc

Host defense
Acquired (Spesific)

Celluler :NK cell, phagocytic

Humoral: active&passive Immunity

Celluler : cytotoxic T-cell, killer cell,

ABS-BIKA FKUSU 31

Lymphokine activated macrophage

INADEQUATE CALORY INTAKE

-QUALITY -IGNORANCE -ANOREXIA

FTT CAUSED BY BOWEL DYSFUNCTION

EXCESSIVE CALORY LOSS

-VOMITING -MALABSORPTION -PROTEIN LOSING ENTEROPATHY

INCREASED NEED

- FEVER

DISORDER OF DIGESTION

MALDIGESTION MALABSORPTION

MALABSORPTION

FAILURE OF THE DIGESTIVE SUBSTRACTS ACROSS LUMEN INTO

MUCOSE
BLOOD

VESSELS
LYMPH

MALABSORPTION

1.MALDIGESTION
2.HYPEROSMOTIC 3.PERISTALSIS

4. ABSORPTION AREA
- SHORT GUT - MUCOSAL INJURY