CONSTIPATION

IN CHILDREN

(FUNCTIONAL OR
ANATOMICAL ANOMALY)
Lulik Inggarwati
Pediatric Surgery Division Surgery Department
Saiful Anwar Hospital/Brawijaya University
Malang
CONSTIPATION
(Functional or Anatomical Anomaly)
BOWEL HABBIT in children
~ NORMAL :
- 350 pre-school children (1-4yo) 96% 3x/day to
alternate daily (UK)
- 800 babies (5do) 4.4/day 13x/day in breast
fed infants (Nyhan)
- Breast & bottle fed babies :
difference (+)
time to 1st stool after passage of meconium ~
same
CONSTIPATION
(Functional or Anatomical Anomaly)
ROME III classification :
- 2 or more of the following features in a child (
developmental age of at least 4yrs) & occuring at least
1/week for at least 2 mo before diagnosis :
2 or fewer defaecations in toilet/week
at least 1 episode of faecal incontinence/week
history of retentive posturing or excessive volitional stool
retention
history of painful or hard bowel movements
large faecal mass in the rectum
history of large stools ~ obstruct the toilet
CONSTIPATION
(Functional or Anatomical Anomaly)
PACCT (The Paris Consensus on
Childhood Constipation Terminology) :
passage of stool in an appropiate place
occuring in children ~ mental age of at
least 4yo
no evidence of constipation on history or
examination
CONSTIPATION
(Functional or Anatomical Anomaly)
Iowa criteria (~ children 2yo) ~ 2 or more
of the following during the previous 8weeks :
1 episodes of faecal incontinence/week
large stools in rectum or felt on abdominal
examination
passing of stools so large ~ obstruct the
toilet
retentive posturin (withholding behaviour)
painful defecation
< 3 bowel movements/week
MECHANISM of Continence
Fecal continence depends upon 3 factors :
1. Voluntary sphincter muscles
2. Anal canal sensation
3. Colonic motility
MECHANISM of Continence
Fecal continence depends upon 3 factors :
1. Voluntary sphincter muscles
Normal patient ~ are represented by :
- levators
- muscle complex
- parasagittal fibres
used only with sensation (be derived from intact anal
sensory mechanism)
ARM : abnormal voluntary striated muscles + different
degree of hypodevelopment
HD : damage sphincter mechanism
Spinal problems : deficient innervation
 FECAL CONTINENCE
Rectal fecal mass

Pushed by
Time of defecation Involuntary
(voluntary peristaltic
contraction) contraction
(rectosigmoid)

Reaches anorectal Relaxation (striated

area rectal muscles)
 FECAL CONTINENCE
2. Anal Canal Sensation
~ No anal canal
anorectal malformation
spinal problems
perineal trauma
~ stool consistency distend the rectum (proprioception)
~ some needs the help medication bulk up the stool
Hirschsprung`s disease?
 FECAL CONTINENCE
3. Bowel Motility
most important factor
ARM :
- disturbance of rectosigmoid emptying overefficient
bowel reservoir (megarectum) ~ PSA or Sacroperineal
approach
- Resection of most distal part bowel ~ behave clinically as
without a rectal reservoir
- Need medical management (enemas, constipating diet &
medications) to slow colonic motility
main clinical manifestation of megarectum ~ constipation
CONSTIPATION
(Functional or Anatomical Anomaly)

SYMPTOMS
Infrequent stools
Pain
Soiling
Stool withholding manoeuvres
Blood in stools
Enuresis & other urinary symptoms
Associations (obesity, poor fluid intake-reduction
in eating/fibre)
CONSTIPATION
(Functional or Anatomical Anomaly)
Caused by :
1. Toilet training issues (early toilet training)
2. Changes in diet (eating more fiber-rich fruits and
vegetables and drinking more fluids)
3. Changes in routine.
4. Medications.
5. Cow's milk allergy.
6. Family history.
7. Medical conditions.
CONSTIPATION
(Functional or Anatomical Anomaly)
Complications
1. Anal fissures
2. Rectal prolapse
3. Stool withholding
4. Encopresis
 DIAGNOSIS
Symptom?
Underlying disease
 RADIOLOGY
Plain abdominal photo
Contrast enema with watersoluble material
~ dilated-constipated or nondilated-tendency toward loose
stool (type and volume the enema)
Should never be done Barium
Postevacuation film
MANAGEMENT
1. Education
child should never be blamed for soiling (should be
explained to parents)
Clear and simple messages
parental/family education
- Understanding of aetiology, symptoms & principles of
management (physiological basis of constipation and
soiling)
- Long-term symptom improvement
- Underlying psychosocial problems (bullying to
pressure to use a single family toilet quickly)
Lack of awareness of most teachers ~ childhood
constipation
MANAGEMENT
2. Diet
- Better fibre intake
- Cow`s milk protein-free diet for :
a. Strong family history of cow`s milk protein intolerance /
Eo count / specific IgE to cow`s milk ~ and in infants
a hydrolysed formula
b. Non-IgE-mediated cow`s milk protein intolerance
(suggestive history if constipation started on switching
from breast-to formula-feeding)
c. Refractory constipation
MANAGEMENT
3. Medications
~ Disimpaction is important (particularly in severe
cases)
orally
initially 2-3 appoinments 1-2 weeks
potentially worsening of overflow soiling initially
diarrhoea (overflow)
risks precipitating acute abdominal pain
(weekends/holidays stress for child & fam)
MANAGEMENT
3. Medications
~ Maintenance therapy
child should be encourage to use toilet regularly
(particularly after meal)
allow the parents to allow to vary laxative dose ~ in
response the child`s symptoms
improvement (+) ~ gradually laxatives & NEVER
stopped suddenly (take place over months even years)
MANAGEMENT
4. Surgical approach (puberty period)
~ Malone procedure (continent appendicostomy)
~ Colonic flap (continent neo-appendicostomy)
allow the parents to allow to vary laxative dose ~ in
response the child`s symptoms
improvement (+) ~ gradually laxatives & NEVER
stopped suddenly (take place over months even years)
 MANAGEMENT
of difficult/ refractory constipation
exclude an organic aetiology ~ full thickness biopsy
multi-disciplinary team approach ( medicinal & dietary
treatment, psychologists and play therapists)
a period of inpatient admission may be useful
surgery : - appropriate organic indications
- fail with medical management at tertiary level
PROGNOSIS
???
THANK YOU