This document covers all the educational activities provided under the theme 'paediatrics' in the abdomen cluster. This covers the learning goals (ie. GERD, obstipation and diarrhoea, abdominal pain), an example of a patient case (SOEPEL), and relevant lectures.
- Definition: near complete constipation often with no underlying medical condition
- Constipation: a delay or difficulty in defecation present for >2 weeks sufficient to
cause significant distress to the patient
- In children the caregiver is often more distressed
- Causes
- Physiological (functional)
- Transition to solid diet (infants)
- Toilet training (toddlers): withholding
- Starting school (young children)
- Stress: at home, at school, abuse …
- Non-Physiological
- Pain: bowel movements can be painful in children so the child can
become constipated from avoiding going to the bathroom
- Stress
- Medications
- Medical condition (occurs in <5% of children)
- Infants
- Neurological: Hirschsprung disease, spinal cord abnormality,
encephalopathy
- Congenital: abnormal anal development, cystic fibrosis
- Metabolic: hypothyroidism, hypercalcemia, hypokalemia, diabetes
1
- Children (>1 yo)
- Neurological: Hirschsprung’s disease
- Metabolic: hypothyroidism, hypercalcemia, hypokalemia, diabetes
- Trauma: spinal cord trauma/abnormality, heavy metal poisoning
sexual abuse
- Congenital: cystic fibrosis
- Autoimmune: gluten enteropathy
- Other: neurofibromatosis, development delay
2. Clinical Features
- Epidemiology
- ⅓ of children between 6-12 yos report constipation during any given year
- Encopresis
- Toddlers: no gender difference
- School age (5yo): 3x more common in boys
,- Normal bowel habits
- 1st week of life: 4 liquid-soft bowel movements per day
- 1st 3 months of life:
- Breastfed: between 1-3 soft bowel movements per day and 1 per week
- Formula-fed: 2-3 bowel movements per day depending on the formula
- By 2 yrs old: 1-2 formed bowel movements per day
- Indication of a functional cause (most common cause)
- History: stool passed within 48 hours of birth, hard large-caliber stools,
encopresis, pain/discomfort, blood on stools, decreased appetite diet low in
fiber/fluids or high in dairy products, avoidance of the toilet
- Physical examination: mild abdominal distension, palpable stool in LLQ, normal
anal placement and anal sphincter tone, rectum packed with stool, presence of
anal wink and cremasteric reflex
- Indication of an organic cause
- Hirschsprung’s: meconium >48hrs after delivery, small-caliber stools, failure to
grow, fever, bloody diarrhea, bilious vomiting, tight anal sphincter, empty rectum
with palpable abdominal fecal mass
- Pseudo-obstruction: abdominal distension, bilious vomiting, ileus
- Spinal cord abnormalities: decrease in lower extremity reflexes/muscular tone
absence of anal wink, presence of pilonidal dimple/hair tuft
- Hypothyroidism: fatigue, cold intolerance, bradycardia, poor growth
- Diabetes: polyuria, polydipsia
- Cystic fibrosis: diarrhea, rash, poor growth, fever, recurrent pneumonia
- Gluten enteropathy: diarrhea after gluten consumption
- Congenital anorectal malformation: abnormal position or appearance of anus on
P.E
3. Treatment and Prognosis
- Treatment
- Non-pharmacological -> if no underlying medical condition
- Increase fibre intake: increases weight of the stool, speeds its passage
through intestines
- A sudden increase can cause bloating and gas → gradually
increase intake
- Over-the-counter fibre supplements can be a solution, but a child
needs to drink a lot of water for them to work
- Adequate fluids
, - Give the child adequate time for bowel movement: encourage them to sit
on the toilet for 5-10 minutes within an hour after a meal
- Physical activity (adults)
- Pharmacological -> if there is a medical condition or if the non-
pharmacological therapy was insufficient
- Laxatives: if an accumulation of fecal material is the cause of the
blockage, this can help
- Prevention
- Eat foods high in fibre
- Drink enough (water)
- Create a toilet route for the child
- Encourage the child to go when nature calls
- Exercise enough (adults)
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