Case Report –EBP

Out patient pediatric clinic

FUNCTIONAL
CONSTIPATION

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 Introduction
Constipation

delay or difficulty in defecation, present for two or more

Definition weeks, and sufficient to cause significant distress to the
patient.

• 0.7% to 29.6%
Prevalence
• First appears  2 - 4 years

Etiology • Organic
• Non organic (functional)

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 Introduction
Functional Constipation
constipation not associated with abnormalities or intake
Definition of medication (= idiopathic constipation, fecal withholding,
and functional fecal retention)

Prevalence • 95%  constipation

• > 1 year
Etiology • voluntary withholding of feces
• stool frequency < 3 x/week, painful defecation,
Symptoms withholding, hard stool, soiling, and abdominal
discomfort.

• Longer duration of symptoms before diagnosispoorer

long term outcome.
Prognosis • Earlier diagnosis and effective management  improve
outcomes.
• Succesfully treated within 5 years  80%.
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AIM

The aim of this paper is to report a case of

functional constipation in a two years old girl.

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 RSS, girl , 2 years , came to outpatient
Case pediatric clinic HAM hospital on August 8th
2012, Main complaint : difficulty in defecation

- Meconium is passed within the - Difficulty in defecation since 15

first 12 hours
- The patient had complete
immunization
- Normal growth and development
- History of feeding 0-6 months
breast milk, 7-11 months
porridge, 12 bulan until now
regular food, low fiber diet
- No family history of constipation
- History of retaining defecation (?)
- Laxative/soapy water (+)
months old
- Defecation twice a week
- Painfull, large diameter stools
- Hard bowel movements
- Last defecation 3 days before
- Nausea, abdominal pain,distention
- Vomiting was not found
- Miction was normal
Reffered by Pediatric Surgery
Department  constipation or
hirschprung disease.
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 Physical examination:
Consciousness : alert , T: 36,9°C, BW: 11.5 kg, BL: 81 cm BW/BL :
94.6%
General condition : good/ Disease condition : moderate/ nutrition: good
Anemia, icteric, dyspnea, cyanotic, edema (-)
Head : Eyes : light reflexes (+), pupil isochoric
Ear/ Mouth/Nose : normal
Neck : Lymph node enlargement (-)
Chest : Symmetrical fusiform, retraction (-)
HR: 104 bpm, reguler, murmur(-)
RR: 30 tpm, reguler, rales (-)
Abdomen : Soft, Peristaltic (+) N, mass (-), liver & spleen : not palpable
Anogenital : ♀, mass (-) or swelling
Ekstremities: pulse 104 bpm, regular, P/V : adequate
BP : 90/60 mmHg
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 Rectal examination : - Anal sphincter was normal
- Fecal mass (+), pain (-)
- Glove: mucous (-), blood (-),
feces (-)
 
 Barium enema result (July 28th 2012):
morbus hirschprung sign (-)

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 Differential diagnosis : 1. Functional onstipation
2. Hirschprung disease

 Working diagnosis : Functional constipation

 Treatment : - Lactulose syrup 2 x 10 ml

 Planning : - Routine blood, electrolyte, blood

glucose, routine feses
- Consult to gastrohepato enterologi division
- Education

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 Gastroenterologi division :
Acording to physical examination, clinical symptom found similar to
functional constipation. Planning: observation (freq and consistency of
stool), and educate the parent to give her high-fiber diet

 Laboratory finding
- Haemoglobin 11.40 g/dL, Hematocrite 34.60%, Leucocytes 10
330/mm3, Platelet 360 000/mm3
- Natrium 135 mEq/L, Kalium 3.6 mEq/L, Chlorida 104 mEq/L, Blood
glucose 94.60 mg/dL
- Feses routine : color yellow, consistency hard, blood
(-), mucous (-), amoeba (-), eritrosit 0-1/HPF,
leucocytes 0-1/HPF
  

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 Follow up on August 20th 2012
S : defecation 3-4 x/week, pain (+), A : Functional constipation
hard bowel movement ↓
O : sens : CM, T: 36.5°C BW: P : Lactulose Syrup 2 x 10 ml
11.5 kg

Head :  Follow up  1 month later

Eyes : lower eyelid pale -/-,
light reflexes (+), pupil isochoric  
Ear/ Mouth/ Nose : normal
Neck : Lymph node enlargement
(-)
Chest : Symmetrical fusiform,
retraction (-)
HR: 100 bpm, reguler, murmur(-)
RR: 28 tpm, regular, rales (-)

Abdomen : Soft, Peristaltic (+) N,

massa (-)
L/S : not palpable 12
 Discussion
 A normal pattern of stool evacuation  sign of health in
children.

 Meconium is passed within the first 24 hours in about 87%

of infants and within 48 hours by 13%

 The method of feeding  impact on stool frequency, colour

and consistency.

 Defecation is a complex process involving a coordinated

activity of the abdominal and pelvic musculature (straining)
and relaxation of anal sphincters.

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 Discussion
 Normal  the resting tonicity of the internal anal sphincter
and enhanced by contraction of the puborectalis muscle
90-degree angle of rectum to the anal canal.

 When > 15 cc of stool enters the normal rectum, stretch

receptors and nerves in the intramural plexus are activated.
Inhibitory interneurons decrease the resting tone in the
involuntary smooth muscle of the internal anal sphincter

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 Discussion

 Relaxing the sphincter and allowing stool to reach the

external anal sphincter that is composed of voluntary
skeletal muscle the urge to defecate is signaled.

 Relaxes the external anal sphincter, squats to straighten

the anorectal canal, and increases intra-abdominal
pressure with the Valsalva maneuver  the rectum is
evacuated of stool.

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Discussion

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 Discussion

 The North American Society for Pediatric Gastroenterology,

Hepatology and Nutrition (NASPGHAN)  Constipation in
children has been defined as a delay or difficulty in
defecation, present for two or more weeks, and sufficient to
cause significant distress to the patient.

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 Discussion

 The Rome II criteria for constipation in infants and children :

- hard stools for a majority of bowel movements for at
least 2 weeks
- firm stool ≤ 2 times per week for at least 2 weeks
- No evidence of structural, endocrine, or metabolic
disease.

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Discussion

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 Discussion

 The causes of constipation

 Organic (5%) anatomic, neuromuscular, metabolic,
endocrine or others.
 Non-organic  majority of case (95%), linked to food,
lack of exercise, and behavioral or psychological
problems

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 Discussion

 Predisposing causes  starting toilet training, change in

routine or diet, change from breastfeeding to cow’s milk,
change from liquid to solid foods, the birth of a sibling,
starting daycare, and traveling.

 Constipation  low fiber diet, psychological factors,

prematurity, and painful defecation

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2

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 Discussion
 The children tighten the external anal sphincter and
squeezes the gluteal muscles if they do not wish to
defecate  push feces higher in the rectal vault  reduce
the urge to defecate.

 Frequently avoids defecating  the rectum streches to

acommodate the retained fecal mass the propulsive
power of the rectum is diminished hard stool

 Passage of a hard of large stool painful anal fissure.

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 Discussion
 The cycle of avoiding bowel movements stool retention
and infrequent bowel movements functional constipation.

 Most children functional constipation

case :
The patient is a girl, 2 years old with main complaint of
difficulty in passing stool since 15 months old.
Meconium is passed within the first 12 hours, defecation
was twice a week, painfull, large diameter stools and
hard bowel movement. History of feeding is low fiber
diet.
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 Discussion
 Signs and symptoms may vary according to the age of the
child.

 Infants  grunting baby syndrome, straining, turning red in

face, grimacing, and crying.

 Toddlers  passing painful and hard stool, bleeding per

rectum secondary to a small tear in the anal canal, and
withholding.

 They perform a dance like behavior, rising on their toes and

rocking back and forth, stiffening their buttocks and legs,
assuming unusual positions, often in a corner.

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 Discussion

 The rectum habituates to the presence of a large amount of

fecal mass, and the defecation urge dissipates retention
behavior is automatic.

 The rectal wall stretches,some stool leaks out perpetual

smell

 Manifestations  abdominal pain, distention, and feeling of

fullness causing nausea, decreased appetite, enuresis and
urinary tract infections

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 Discussion
 History, physical examination, and rectal examination 
differentiate functional constipation from fecal retention due
to anatomic, neurologic, or organic disease.

 History of painful defecation, passage of huge stools at

infrequent intervals, and retentive posturing  functional
constipation.

 Some children with functional fecal retention have several

bowel movements per day and never or rarely eliminate a
huge stool. Documenting a large fecal mass in the rectum
confirms the functional fecal retention.

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 Discussion
 No or minimal laboratory work-up, include blood studies,
urine culture and abdominal radiographs.

 Plain abdominal film  children for assessing the presence

or absence of retained stool in a child with absence fecal
mass on abdominal and rectal examination, refuse the
rectal examination, obese and evaluation for giving laxative
treatment.

 The barium enema  assessing the transition zone of

aganglionic bowel.

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 Discussion
 Anorectal manometry  evaluate internal anal sphincter
relaxation and determine the level of pressure awareness in
older children.

 The value of the suction rectal biopsy has increased with

the ability to stain the tissue for both ganglion cells and
acetylcholinesterase.

Case:
anamnesis and physical examination we found similar
to functional constipation.
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 Discussion
 Differential diagnoses constipation  organic or non
organic.

 Complications of childhood constipation  abdominal or

rectal pain, encopresis, enuresis, dilated lower colon,
protein-losing enteropathy, pseudo-obstruction, rectal
prolapse, and solitary rectal ulcer syndrome

 Flatulence and the odor of encopresis can be very

debilitating to any child.

 NASPGHAN  4 treatment of chronic constipation are

education, disimpaction, prevention of re-accumulation of
feces, and follow-up.

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 Discussion

 Education and support for parents and children important

 The parents  normal range of frequency of bowel

movements, etiology of constipation, and prevalence.

 Time point of success of treatment is often unpredictable

and 50% of treated patients experience a relapse within 1
year

 The duration of maintenance therapy usually is 6 to 24

months.

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 Discussion
 Rectal disimpaction  before initiation of maintenance
therapy is recommended to prevent increases in abdominal
pain and fecal incontinence due to overflow diarrhea once
treatment has started.

 The agents  magnesium hydroxide, magnesium citrate,

lactulose, sorbitol, polyethylene glycol, senna and
bisacodyl.

 The goal is to produce soft, painless, and bowel

movements once or twice per day.

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 Discussion
 Maintenance treatment to prevention of re-accumulation of
feces include behavior modification, diet intervention, and
laxative.

 Behavior modification  regular toilet use and learning to

relax the pelvic floor and anal muscles during defecation
attempts.

 Parents are asked to keep a stool diary, recording bowel

movements, encopretic episodes, medication use,
abdominal pain, and urinary incontinence.

 This can be combined with a reward system.

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 Discussion
 Fiber balanced diet (recommended grams of fiber are 1
g/year of age plus 5 g) and regular meal times.

 Daily defecation is maintained by daily administration of

laxatives after disimpaction.

 Laxatives are used according to age, body weight, and

severity of the fecal retention.

 Induce 1–2 bowel movements/day and prevent fecal

retention and encopresis.

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Discussion
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 Discussion

 The frequent follow up to assess and promote patient

compliance and adequacy of treatment.

 Follow up at 1 to 2 weeks, then 1 month, 3 months, and 3 to

6 month intervals  to ensure an effective maintenance
phase.

 Approximately 50% of all children who were monitored for 6

to 12 months  recover and successfully discontinued
laxative therapy.

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 Discussion
 Psychological treatment  improve the fecal retention and
encopresis in all children.

 Biofeedback to train patients to relax their pelvic floor

muscles during straining and to coordinate this relaxation
with abdominal manoeuvers to enhance the entry of stools
into the rectum.

 Surgical  for children suffering from intractable

constipation which does not respond to intense medical
management.

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 Discussion

 Sigmoid colectomy was a suggested option in severe

cases.

we given laxatives 10 cc twice a day (1-3

ml/kgbw/day) and education for parents to
give fiber dietary, toilet training, observation
and follow up defecation problem.

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 Discussion
 Prognosis for full recovery has been reported as 48% at 5
years follow up.

 In one study found that 30% of children who had been

treated medically for constipation for a mean of 6.8 years
continued to have intermitten constipation.

 Early onset of symptoms during the first years, family

history of constipation, and poor self esteem are associated
with poor prognosis.

Prognosis was good if the parents given

maintenance fiber dietary for their children.
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 Conclusion

 It has been reported a case of 2 years old girl with

functional constipation.

 The diagnosis was established based on anamnesis and

physical examination.

 She observed after given therapy and got education for her
parents.

 She need follow up and counseling about functional

constipation.

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EVIDENCE BASED PRACTICE
  
A. Clinical question
Does nonpharmacologic give better outcome for treatment for chilhood with
constipation?
 
B. Component of foreground question (PICO)
Patient : Children with constipation
Intervention : Nonpharmacologic treatment
Comparison : -
Outcome : Cure of constipation
 
C. Searching method
We did a search with keyword “constipation” and “nonpharmacologic” and
“meta-analysis” in the Google search engine and we found an article that
can answer the PICO question with the title: “Nonpharmacologic tretment
for chilhood constipation: Sytematic review” that was published in
Pediatrics. 2011; 128:753-61

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SYSTEMATIC REVIEW APPRAISAL
 
Nonpharmacologic treatments for childhood constipation: systematic
review

- Are the results of the review valid?

■ Yes No Unclear
 
- What question (PICO) did the systematic review address?
■ Yes No Unclear
The main question being addressed is does nonpharmacologic give
better outcome in treatment constipation
 
- Is it unlikely that important relevant studies were missed?
■ Yes No Unclear
Available at data sources and table 2

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- Were the criteria used to select articles for inclusion appropriate?
■ Yes No Unclear
The inclusion and exclusion of studies in this systematic review are
clearly defined in methods section. All retrieved articles were screened
on the basis of title and abstract. Full text papers were obtained for
studies selected for further evaluation.
 
- Were the included studies sufficiently valid for the type of question
asked?
■ Yes No Unclear
The methods section describe data from each study. In this systematic
review, all the studies is RCT.

- Were the results similar from study to study?

Yes ■No Unclear
The results of the studies are not similar. Many studies in this
systematic review use different nonpharmacologic. Chi-square test is
used for the heterogenity.

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- What were the results?
In this review, some evidence shows that fiber may be more effective
than placebo in improving both the frequency and consistency of stools
and in reducing abdominal pain, no evidence that water intake
increases or that hyperosmolar fluid treatment is more effective in
increasing stool frequency or decreasing difficulty in passing stools, no
evidence to recommend the use of prebiotics or probiotics and
behavioral therapy with laxatives is not more effective than laxatives
alone.
 
Conclusion :
Compared with placebo, nonpharmacologic were associated with
higher rate on improvement, some evidence that fiber supplements
were more effective than placebo in the care of children with
constipation.

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Thank You

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