abbey rupe, md 2.7.12. “rome iii” diagnostic categories of functional disorders of defecation...
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“Rome III” diagnostic categories of functional disorders of defecation in children:◦ Functional constipation
In infants and preschool children In children 4-18 years of age
◦ Infant dyschezia◦ Nonretentive fecal incontinence
Infants and toddlers: 2 or more of the following present for at least 1 month:◦ 2 or fewer defecations/week◦ At least 1 episode of incontinence after being
toilet trained◦ Hx of excessive stool retention◦ Hx of painful or hard bowel movements◦ Presence of large fecal mass in the rectum◦ Hx of large-diameter stools that may obstruct the
toilet
Children w/ developmental age 4-18 yrs; at least 2 of the following present for at least 2 months:◦ 2 or fewer defecations/week◦ At least 1 episode of fecal incontinence/week◦ Hx of retentive posturing or excessive volitional
stool retention◦ Hx of painful or hard bowel movements◦ Presence of a large fecal mass in the rectum◦ Hx of large-diameter stools that may obstruct the
toilet
Organic causes: < 5% of cases◦ Anatomic: anal stenosis, imperforate anus◦ Metabolic/GI: hypothyroidism, CF, diabetes
mellitus, celiac disease◦ Neuropathic: spinal cord abnormalities, tethered
cord◦ Intestinal nerve/muscle disorders: Hirschsprung
disease, neuropathies◦ Misc: cow’s milk protein intolerance, lead
ingestion, vit D intoxication, botulism
3 periods when kids prone to develop constipation:◦ Introduction of cereals and solid food to infant’s
diet◦ Toilet training◦ Starting school
Painful defecation◦ Can start a vicious cycle
Toilet training◦ Stool is held for longer periods between BMs◦ Power struggles can develop
Diet◦ Highly processed foods consumed at the expense
of fruit, veggies, and fiber Cow’s milk and constipation???? controversial
History◦ Delayed passage of meconium◦ Painful defecation◦ Blood on stool◦ Toilet training issues◦ Voiding dysfunction and enuresis◦ Diet◦ Changes at home/school◦ Family hx
Hx: signs suggesting possible organic cause:◦ Weight loss or poor weight gain◦ Anorexia◦ Delayed growth◦ Delayed passage of meconium (after 48 hours)◦ Urinary incontinence◦ Passage of blood (unless due to anal fissure)◦ Constipation present since birth/early infancy◦ Acute constipation◦ Fever, vomiting, diarrhea◦ Extraintestinalsx
Physical exam◦ Abdominal distention◦ Mass in suprapubic area◦ Anal fissure◦ Soiled underwear◦ Anal sphincter tone◦ Size of rectal vault◦ Impacted stool◦ Lower back skin defects
PE findings suggestive of organic cause:◦ FTT◦ Abdominal distention◦ Lower spine abnormalities◦ Anteriorly displaced anus◦ Tight, empty rectum in presence of palpable fecal
mass◦ Absent anal wink◦ Absent cremasteric reflex◦ Decreased lower extremity tone or strength
Laboratory (if indicated)◦ KUB◦ CBC◦ Thyroid◦ Celiac disease panel◦ Barium enema◦ Anorectalmanometry◦ Rectal biopsy◦ Motility studies◦ Sweat chloride
Findings supportive of functional etiology:◦ Onset coincides with dietary changes, toilet
training, or painful bowel movements◦ Stool withholding behavior◦ Good response to conventional treatment
Breast-fed infants: average 3 stools/day◦ Range: BM with every feed to BM every 7-10
days Formula-fed infants:
◦ Average 2/day◦ Can vary with formula
Soy-based—tend to produce harder stools; hydrolyzed casein formulas tend to produce looser stools
Grunting, apparent straining, turning red in the face, etc does not necessarily mean an infant is constipated◦ More appropriate measure is consistency of the
stool◦ Efforts >10 minutes to produce soft stool: “infant
dyschezia” – failure to relax pelvic floor during defecation effort; resolves spontaneously with time
“normal” stools◦ Reassure, reassure, reassure◦ Press on feet, press knees to belly, raise vertical,
etc Constipated:
◦ 1 tsp dark Karo syrup bid◦ Miralax◦ Glycerin suppository◦ Juice—pear, apple, prune◦ If on solids:
increase pear, prune, plums, beans, peas, peaches Decrease rice cereal, applesauce, bananas
Goal: 1 soft, easily passed stool daily Education
◦ “cycle” of constipation◦ Length of treatment◦ Safety of medication used
3 phases:1.Disimpaction2.Maintenance3.Follow-up
Options: oral or NG medications, rectal medications, or combination◦ Inpatient vs outpatient
Oral:◦ Polyethylene glycol (Miralax)◦ Polyethylene glycol-electrolyte solution◦ Mineral oil (don’t use if at risk for GER)◦ Other: magnesium hydroxide, magnesium citrate,
lactulose, sorbitol, senna, bisacodyl
Rectal◦ Phosphate sodium enema (2 yrs and older) ◦ Mineral oil enema◦ Bisacodyl suppository (older children)◦ Glycerin suppository (infants)
Polyethylene glycol (PEG 3350, Miralax)◦ Osmotic laxative◦ OTC◦ 0.4-0.8 grams/kg/day
Mix in 4-8 ounces liquid Increase or decrease by ½ to 1 tsp every other day
until stools soft and daily
Mineral oil◦ Lubricant laxative
? Interfere with absorption of fat soluble vitamins Administer in mid-afternoon and bedtime +/- give multivitamin
More palatable if chilled and served with a fat-containing food the child likes (pudding, yogurt, ice cream, chocolate syrup)
Avoid in kids < 1 yr of age and those at risk for GER (aspiration pneumonitis)
Behavior modification:◦ “scheduled sitting” on the toilet for 5-10 minutes
at same time each day (preferable within 30 minutes after a meal) Provide footstool for support if needed
◦ Reward system “Poop Journal”
Dietary changes◦ Increase intake of fruit, raw veggies, bran, whole-
grain breads, cereals, and fluids other than milk◦ Cow’s milk
Consider 1-2 week trial of elimination in atopic children whose constipation is unresponsive to other measures
◦ ?probiotics
When to discontinue medications?◦ Depends on child and severity of constipation◦ Taper gradually, resume if constipation returns
Constipation with fecal incontinence—80-95%
Nonretentive fecal incontinence—5-20%◦ Rome III criteria:
Children with developmental age of >4 yrs, with all the following present for at least 2 months: Defecation into places inappropriate to the social
context at least once/month No underlying disease process to explain the symptoms No evidence of constipation
Causes: unclear◦ Some association w/ behavioral and attention
problems as well as anxiety and depressive symptoms
◦ Soiling episodes often linked to certain persons or situations
◦ Up to 40% have never been fully toilet trained
Treatment:◦ No widely effect treatments ◦ Behavior modification
Highly structured toilet training protocol aimed at frequent efforts at defecation
Reward system◦ Psychosocial diagnosis and support
Outcome: ◦ one study found 29% resolution at 2 yrs, 65%
after 5 yrs, and 90% after 10 years
Consider when oral and/or rectal medications are ineffective for disimpaction or when dietary and laxative therapy are ineffective◦ Complete laboratory data prior to consultation
(thyroid, calcium, celiac disease, lead) Referral options:
◦ Wichita: 2 peds gastroenterologists◦ Children’s Mercy: peds GI, BRICK clinic
Acute◦ Passage of loose or watery stools at least 3x/day
in a 24-hour period◦ Lasts <14 days
Chronic◦ Stool volume of >10 gm/kg/day (infants/toddlers)
or >200gm/day (older children) x14 or more days Typically means: loose or watery stools occurring at
least 3x/day
Etiology◦ Infectious gastroenteritis
Acute watery diarrhea Rotavirus (infants/young children) E. coli (older children)
Invasive (bloody) diarrhea—frank blood in stool + fever Shigela Salmonella Campylobacter EHEC EIEC
◦ Other: influenza, HIV, pneumonia, UTI, meningitis, sepsis
Assessment:◦ Type of diarrheal illness (watery, invasive,
chronic)◦ Assess hydration◦ Assess comorbid conditions
Clinical feature
< 5 % dehydrated
5-10 % dehydration
>10% dehydration
Gen. appearance
Well, alert Restless, irritable
Lethargic or unconscious
Eyes Normal Sunken Sunken
Thirst Drinks normally, not thirsty
Thirsty, drinks eagerly
Drinks poorly or unable to drink
Skin pinch Goes back quickly
Goes back slowly
Goes back very slowly
Estimated fluid deficit
< 50 ml/kg 50-100 ml/kg >100 ml/kg
Not indicated in most cases Dehydration requiring IVF Stool studies:
◦ Viral antigen (rota)◦ Culture (bloody diarrhea)◦ O and P (recent travel)◦ C. diff (recent abx)
Fluid and electrolytes◦ Replacement◦ Maintenance
< 2 yrs: 50-100 ml ORS/episode of V/D > 2 yrs: 100-200 ml ORS/episode of V/D
Oral Rehydration Solution◦ Mixture of water, salts, and glucose◦ Pedialyte, etc
IVF◦ Rehydrate with NS boluses (20 ml/kg), followed by
dextrose-containing IVF
Refeeding◦ Feeding can be resumed as soon as rehydration is
complete Feed age-appropriate diet BRAT is unnecessarily restrictive
Pharmacotherapy◦ Antibiotics—not indicated◦ Antidiarrheal—not recommended
Antimotility (i.e. loperamide)—not recommended due to side effects (lethargy, CNS depression, etc)
Antisecretory (i.e. bismuth)—contain salicylates (EVEN Children’s PeptoBismol)
◦ Probiotics Reduce stool output and diarrhea duration
◦ Antiemetics--controversial
Post-enteritis syndrome◦ Most acute enteric infections resolve within 14
days◦ Occasionally, acute GE can cause mucosal
damage to small intestine and trigger chronic diarrhea ? Secondary to transient lactase deficiency Probiotics may speed recovery
DDx list is HUGE!◦ Functional
Excessive juice/osmotically active carb intake Idiopathic
◦ Enteric infection Postentereitis syndrome Parasites Bacteria Viruses
CMV, rota, HIV
DDx, cont’d◦ CF◦ Immune deficiency◦ Abnormal immune response
Celiac disease Food allergic enteropathy
◦ IBD◦ Protein losing gastroenteropathy◦ Factitious diarrhea
Lab◦ Celiac serology (anti-tTG)◦ Stool pH, electrolytes, reducing substances◦ Occult blood and leukocytes◦ Stool fat◦ Concern for IBD: CBC, albumin, ESR ◦ Sweat chloride◦ Fecal elastase
Aka Functional Diarrhea or Chronic nonspecific diarrhea of childhood:◦ Painless passage of 3 or more large, unformed
stools during waking hours for 4 or more weeks◦ Onset in infancy or preschool years◦ Without FTT or specific definable cause
Early morning stools: large and semi-formed Stools become progressively looser as day
progresses Nearly all will develop normal bowel
patterns by 4 yrs of age
Sometimes due to excessive intake of fruit juice◦ Improves if intake is decreased
No other dietary modification needed
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