encopresis 1

7/28/2019 encopresis 1

1/34

Chronic Constipationand Encopresis

Vctor M. Pieiro, M.D.

Uniformed Services University

Bethesda, Maryland


2/34

Definition and Frequency

Constipation is a symptom, not adisease

Stools are small, hard or

infrequent

3% of outpatient pediatric visits

10-25% prevalence in PediatricGI practice


3/34

Constipation

Most common GI outpatient problemMay start at any age

Rarely due to structural abnormality or

systemic disease

Children DO NOT outgrow it

spontaneously

Prognosis is good if treated

appropriately


4/34

Normal Bowel Habit

Pre school children

Stool frequency QOD - TID (95%)

Stool weight 25 gms

Transit time 33 hrs

Toilet training ages 2-3 yrs.


5/34

Colonic Motility

Colon has complex motility patterns

Colonic contents moved to the cecum by

waves of "antiperistalsis"

Colonic haustrations prominent in

transverse and descending colon

Giant migrating contractions originate

in transverse colon and rapidly reachthe rectum (gastrocolic reflex)


6/34

Mechanisms of Defecation

Inflation Reflex

Seen after age 2

Distension of rectum

Stimulus sensory nerves

Conscious awareness

Transient relaxation of external anal

sphincter (EAS)


7/34

Mechanisms of Defecation

Rectosphincteric Relaxation Reflex

Distension of rectum

Sensory nerves (via myenteric plexus)

Inhibition of smooth muscle internal

anal sphincter

Relaxation of IAS


8/34

hronic Idiopathic ConstipatioMale predominance 1.5:1

Age of onset 0-1 yr 25%

0-5 yr 70%

Event at onset 30%

Large stools 75%

Withholding behaviors 40%

Failed toileting 30%


9/34

Clinical Presentation

Family history 10-50%

Rectal bleeding 25%

Enuresis/UTIs 15%

Abdominal Pain 10-50%

Psychologic problems 20%

Rectal prolapse 3%

Poor appetite 26%

Previous therapy 90%


10/34

Clinical Presentation

Physical examination

Abdominal distention 20%

Abdominal mass 30-50%

Fecal impaction 40-50%

Weight < 5% 0-10%


11/34

Anorectal Manometry

Proximal rectal balloon to distend the

rectum

Pressure sensors used to measure IASand EAS

Distention of rectum triggers the

Inflation and Rectosphinctericrelaxation reflexes


12/34

Pathophysiology

I. Resting anal sphincter pressure

Increased, normal or decreased

II. Rectosphincteric relaxation reflex

Critical volume ( minimal volume of

rectal distention required to elicit the

relaxation reflex) is often increased


13/34

Pathophysiology II

III. Rectal Sensitivity - ConsciousAwareness

Threshold volume (volume required to

produce conscious awareness) is oftenincreased

In encopresis IAS relaxation occurs at

volumes that do not stimulate

conscious awareness


14/34

Pathophysiology III

IV. External anal sphincterParadoxical EAS contraction

(unconscious EAS contraction during

defecation) in severe constipation

V. Expulsion failure

Patients with severe constipation and

encopresis may have an inability to

defecate balloons


15/34

Potentiation of Risk for Encopresis

Stage I Infancy and Toddler Years

Simple constipation

Congenital anorectal problems

Parental overreaction

Coercive medical interventions


16/34


Stage II 2 to 5 years

Psychosocial stresses

Coercive or permissive training

Toilet fears

Painful or difficult defecation


17/34


Stage III Early School Years

Avoidance of school bathrooms

Prolonged gastroenteritis

Attention deficit disorder

Frenetic life-stylesPsychosocial stress


18/34

Differential Diagnosi


19/34

Medical

Hypothyroidism Diabetes insipidus

Hypokalemia RTA

Hypercalcemia Botulism

Uremia CNS disorders

Depression Anorexia nervosa


20/34

Gastrointestinal Disorders

Intestinal Pseudo-obstruction

Cystic fibrosis

Crohn's disease

Celiac disease


21/34

Drugs and Toxins

Anticholinergics Iron

Anticonvulsants BismuthOpiates Lead

Antidepressants Barium


22/34

Anatomic

Anorectal anomalies

Spinal cord injury

Sacrococcygeal teratoma

Hirschsprung's disease

Meningomyelocele


23/34

Anterior Anal Displacement

Anterior ectopic anus

Anal canal + IAS anteriorly located

EAS in normal positionAnteriorly located anus

Anal canal + both sphincters anteriorly

located

A i A i


24/34

Anterior Anal Displacement

Rectal exam

Posterior angulation of anal canal

Posterior shelfTreatment

Often conservative

Surgical repair if severe


25/34

Hirschsprung's Disease

Congenital Aganglionosis of colon

Rectosigmoid colon 80%

Transverse/Ascending 15%Total aganglionosis 5%

Ultrashort Rare


26/34

Hirschsprung's DiseaseBarium enema

Distal narrowed segment, transition zone,

"saw-toothed" contractions

Anorectal manometry

Lack of rectosphincteric relaxation reflex

Rectal biopsyDiagnostic (adequate specimen, expert

atholo ist

E i


27/34

Encopresis

Weissenberg - 1926

Involuntary passage of whole bowel

movements in the underwear or on

abnormal place

Now commonly used synonymously

with fecal incontinence or soiling


28/34

Treatment

Must explain the pathophysiology of the

problem

Improves compliance with therapy

Alleviates the guilt and blame the

parents may feel

Decreases embarrassment child isexperiencing


29/34

Treatment

Three Stages

Education

Initial Catharsis (Whoosh)

Maintenance

C h i


30/34

Catharsis

Day 1 Magnesium citrate 5-10 oz. P.O.

Days 1-3 Mineral oil enema 3-4 oz. PR

Days 1-3 Fleet enema 2-4 oz. PR

Days 2-4 Dulcolax 5-10 mg. P.O. QD

M i t R i


31/34

Maintenance Regimen

High Fiber Diet

MOM 0.5-1 ml/kg/dose BID

Mineral oil 0.5-1 ml/kg/dose BID

Behavior modification (Toilet training)

Follow up visits every month

A l P i i I d


32/34

Anal Position Index

Ratio of anus-fourchette distance tococcyx-fourchette distance (scrotum in

males)

BA

Normal Ratios A/B

> 0.34 in females

> 0.46 in males

{

}

Di ti E l ti


33/34

Diagnostic Evaluation

Complete History and PhysicalExamination

Laboratory Studies

CBC, ESR, U/A, Urine culture

Stool culture, O & P, occult blood

Serum glucose, calcium, phosphorusThyroid function studies



34/34


Radiographic Studies

Abdominal plain film, BE

Special diagnostic Studies

Rectal suction biopsy

Anorectal manometry

Indicated Studies

UGI/small bowel series

Proctosigmoidoscopy, colonoscopy

Pelvic MRI

encopresis 1

Documents