CONSTIPATION

CONSTIPATION









Dr. Soad Jaber

2009

Constipation

 Physiology of defecation

 Understand the differences between

 Constipation

 Encorporesis

 Soiling



 Identify major causes of constipation

 Differences between functional and

organic causes

 Understand the principle behind

constipation management

CONSTIPATION

Physiology of defecation

 In normal subjects : Distention of the rectum

Reflex relaxation of internal sphincter

Contraction of external sphincter



*Lower rectum is normally empty

*Entry of fecal material from above gives the sensation of the

need to defecate.



 If the rectum is chronically distended the sensation is lost 

retention of stool  full rectum

Constipation:





 Delay or difficulty in defecation that

has been present for two weeks or

longer. is associated with anal and

abdominal discomfort.

 Full rectum

Functional Constipation:

Is a voluntary withholding of stools

Starts after the neonatal period

Usually develop after passage of

painful bowel movement.

Encopresis:

 Day or night time passage of formed

stool into inappropriate places

beyond the age expected for toilet

training (4-5 year

 Abnormal anal sphincter physiology.

Types of Encopresis:

A)RETENTIVE encopresis with constipation (A

and overflow incontinence.2/3

B)Non RETINTIVE encopresis: without

constipation and overflow.1/3 (A









OR :1ry from infancy occur with global (B

developmental delay and enuresis.

2ry:after successful toilet training occur with (C

psychosocial stress and mismanagement

Soiling:

Involuntary escape of fluid or semi

fluid stools into the under clothing

usually due to overflow from a

loaded cecum with feces which leads

to stretch of internal sphincter

Neurogenic Soiling:



Soiling which occur due to neurological

abnormalities:



Spinal bifida

Paraplegia

Myelomengiocel

Causes of Constipation:

A. Infants and Children:



1. Non-organic Causes

.Lack of dietary fibers

.Inadequate fluid intake

.Failure to develop regular bowel habits

(neglect, stubborn child, MR)

.Follow illness

.Change in environment or routine

(Holidays… school entry)

Organic cause



Anatomic(anaal 

stenosis,imperforatecanus,anteriorly

displaced anus.intestinal stricture)

Abnormal musculature(prune-belly 

syndrome,Gastroschisis,Down syndrome

Intestinal nerve or muscle 

abnormalities(Hirschprung diease)

Spinal cord defects(spinal cord trauma or 

spina bifida)

Drugs(Anticholinergics or 

narcotics 48h or early

onset of constipation

 Empty rectum on examination Normal anal

tone

 Absence of ganglia in rectal sub mucosal

biopsy

 Barium enema  transition zone

 Manometery --- absence of internal

sphincter relaxation

Conflict in training

Stool retention



Pain in defecation



withholding the stools



 distention of the rectum



 Rectal sensation



necessitating a greater fecal

mass to initiate the urge to

defecate

Complication of stool retention

 Impaction

 Abdominal pain



 Overflow diarrhea  leakage around the

fecal mass

 Anal fissure



 Rectal bleeding



 Urinary tract infection

Management:

 History and clinical examination

should reduce the number of

investigation

e.g. anal fissure

 History of change in environment or

diet

 Presence of hard impacted stools

 Barium study:?XRAY

.large rectum or recto -segmoid

.impaction of stool

B. Elder Children

 He might present with recurrent

abdominal pain

 He might develop soiling

 The elder child will eventually reach the

stage where he is very quiet, withdrawn

and isolated from his classmates

 Parents and child should participate in a

group discussion and plan the

management to help the child



*If with soiling advise of Psychiatrist

Medical

1. Hypertonic phosphate enemas daily

or every other day for 1 week.

2. Mineral oil 30-60 mls twice daily

between meals to minimize its effect

in impairing the absorption of fat

soluble vitamins --  with the

response to stop within the period of

about 6 months.

3. Ensure that the child has sufficient

fluid and fiber in the diet

4. Bulk type of softness (Metamucil)

maybe administered as the dose of

mineral oil is tapered.

5. Lactulose, senna, may have to be

prescribed to break the vicious cycle

of fecal retention and pain

Dietary Measures

 Intake of fluid

High residual diet, bran – whole

wheat

Fruit and vegetable

Prune Juice



Anal Dilatation

 Old method – local anesthesia

 Well lubricated little finger inserted

into the anus and kept for 1 minute

INFANTS

*Treat the cause

 Simple constipation … correct diet … add

fiber… treat anal fissure .. Softening the

stool to break the cycle

 Daily stitz bath



 Application of Vaseline ointment after the

bath

 Anesthetic ointment.

Managements:

Hx Onset

Associated findings

FTT  organic

Ex Abdominal

Rectal

Signs of Hypothyroidism

Explanation Common problem

Will get better



Physiology of defecation



Long term managements up to 1 year

Goals:



1. Empty Rectum

Clean out retained stool

Enema

Suppositories

Senakot

Bowel cleaning

2. Bulky stool

High fiber diet (bran)

3. Improve habits

Regular time of toilet after feed

Stars chart

Position- squatting

De emotionalize home

environment

Functional Constipation:

WHY MAY THE TREATMENT FAIL ?!



 Inadequate clean out 

suppositories

 Inadequate dosage of medication



 On and off approach:



Intermittent use of medication

Malabsorption

Objectives:

 Digestion



 Definition



major causes of

 Identify

malabsorption

 Know to work up for malabsorption

Malabsorption

Digestion



 Stomach ------- breakdown ingested food

by rhythmic contraction

gastric acids.

 Small bowel---- Intestinal secretion 

digestion.





*Brush Border

Small bowel 2 halves



Jejunum CHO maltose

Fat F.A. mono glycerides

Protien..di ,tri, tetra peptides + a.a.

Minerals

Vitamins

Water



Ileum Water

B12

Bile salts

Malabsorption Syndromes

Malabsorptive disorders

They are conditions that cause insufficient assimilation of ingested

nutrients either as a result of mal digestion, or malabsorption.



General presentation:

Abdominal distention

Pallor

Foul smelling stools

Bulky stools.. Normal… greasy…steatorrhea

muscle wasting

Poor weight gain … weight loss

Growth retardation

Clues:

Acute diarrhea --- infection

chronic diarrhea > 3 weeks ? Malabsorption

Blood,FTT



Overall appearance of the child

I. Malabsorption according to age

of presentation

1. From birth up to two years of age:

– Post infectious

– Protein intolerance

– Congenital microvillus inclusion disease.

– Glucose – galactose transport defects.

– Congenital chloride diarrhea

– Familial chronic villous atrophy

– Immune deficiency disease

– Cholestatic liver disease

– Gluten sensitive enteropathy

– Anatomical cause (short bowel syndrome)

2. Older children:

– Cystic fibrosis

– Crohn’s disease

– Gluten sensitive enteropathy

– Acquired lactose deficiency

II. Malabsorption according to

substances:

1. Fat

Celiac disease

Cystic fibrosis

OTHERS:

Giardiasis

Congenital intestinal malformation

Crohn’s disease

Biliary atrasia

Liver cirrhosis

2.Carbohydrate

Glucose -galactose transport

defect

Genetic Lactose (Primary lactase deficiency)

Sucrose (Congenital sucrase –

isomaltase deficiency)







Secondary celiac disease

any chronic diarrhea

3. Protein

Follow any chronic diarrhea

Enzyme deficiency (trypsinogen)

Allergy… Cow’s milk protein



4. Vitamins

Fat soluble Vit. Secondary to

steatorhea

B12 … Crohn’s

III. Malabsorption according to site

of defects.

1. Mucosal

Small intestinal injuries resulting in secondary

deficiencies.

- Celiac disease

- Bacterial over growth

- Cow’s milk enteropathy

- Giardiasis

- Rota virus infection

- Chronic protracted diarrhea

- Protein energy malnutrition

- Crohn’s disease of small intestine

- Short bowel syndrome

- Drugs …neomycin … colchicines

- Radiation enteritis

2. None mucosal

Pancreatic disease ------ cystic fibrosis



Bile losses ---- bacterial overgrowth



deconjugation of bile acids



Cholestasis



Lymphatic obstruction------

lymphagiactasia

A Beta–lipo proteinemia

How to approach:

History:

 Is he/she thriving

 Weight/height

 Appetite

 Other symptoms --- edema

 Repetition of symptoms with reintroduction of certain foods

e.g. Gluten

Lactose

Cow’s milk

 Stool Greasy

Oil slik in the toilet

Frothy – sugar intolerance

Smell --- Rancid, CF

-----foul, celiac

Examination

Growth chart

Pallor --- Iron, folate

Clubbing CF, IBD, CD

Chest problem CF

Distended abdomen CD

Muscle hypotonia + wasting

Nappy rash

Rectal examination (prolapsed)

Laboratory investigations:

1. Stool

1.microscopic examination

– Fat droplet (stool + water + Sudan red stain)

– 72 hours stool collection

– Stool Giardia Cyst

ELISA for Giardia antibodies.

2. Stool PH  5.6 (CHO)

3. Spot  antitrypsin level ( 2 days stool)

4. Stool reducing substance

– Chromatography

– Clintest tab

10 drops water + 5 drops stool+tab



(-ve -- 4+) Color coding 2 + or 

suggest CHO malabsorption

Sucrose is not reducing substance

Should be hydrolyzed by HCl before analysis

5. Stool osmolarity (stool electrolyte content)

290 - 2(Na + K ) meq/L

  100 mosm/L  secretary as in cong chloride

diarrhea

  100 mosm/L  Osmotic diarrhea  CHO

intolerance

2. Blood

 CBC— blood film------- A canthocyte

hypochromic, microcytic anemia

macrocytosis

 Serum albumin

 Serum immunoglobulins

 Trypsinogen (screening)

 Nutrients in blood

Iron .. Transferrin concentration

folic acid –---- RBCs concentration , not serum

Ca, Mg, Vit D., Vit A

B12 -- bile salt

Vit E + Serum lipids

Vit K ( PT , PTT)

3. Others



 Sweat chloride test

 Hydrogen breath test



 D-xylose test



 Schilling test (Vit B12)

4. Diagnostic Procedure:



1. Small bowel biopsy:



1. Duodenal mucosa

Giardia trophozoite

Colony count of bacteria

Culture of proximal juice

2. For HIV

parasitic bacteria or virus

viral opportunistic entral pathogen

3. Gluten sensitive enteropathy

Challenge test

4. Congenital microvillous inclusion disease

5. Eosinophillic gastroenteritis

6. Infectious disorders

2. Imaging procedure

X-ray – site of colon - e.g. intestinal mal rotation

Ultra sound (biliary tree.. Pancreas)

Barium contrast meal and follow through

Barium enema

Review of some disorders

I. Disorders of CHO intolerance

Symptoms

Flatulence, Diarrhea, bloating, vomiting, abdominal

cramping, barborygmi



A. Congenital Disorders

 Lactose deficiency

cong (rare) Acquired

TX Lactose hydrolyzed milk.

Lactid tab



 Sucrase deficiency:

Recurrent watery diarrhea, stool PH below 6



 Glucose – Galactose malabsorption.

Very rare neonates severe hypoglycemia –

acidosis

TX fructose formula

B. Acquired disorders:

 Secondary to acute viral OR bacterial

gastro enteritis…. lactase def > sucrase

 Generally children tolerate lactose

withen (3w-3m)

Stool PH 6

+ve clinitest tab

 Secondary to celiac disease, Crohn’s

disease, ulcerative colitis

TX – lactose free diet

II. Disorders of Proteins

 Cow’s milk protein sensitivity

A topic individuals

Jejunal atrophy

Colonic bleeding

Iron deficiency anemia unresponsive to

treatment with oral iron.



TX D/C milk

Repeat challenge with carefully increasing

dose majority will tolerate milk by two years.

40% intolerant to Soya protein.

 Celiac disease

Allergyto Gliaden portion of gluten

(wheat, Rye, Oats or barley)

– Screening antibodies

Antigliadin IgA, Anti reticulin, Anti

endomyseal EMA

Celiac Sprue: Gluten sensitive enteropathy



C/P Abdominal distention Weight loss –FTT

irritability Vomiting Steotorrhea

mild cases, IDA,,, short stature ,,,delayed puberty



Investigation:  Serum Iron  folic acid  albumin

Flat Glucose tolerance test EMA +ve,, ,+ve

Antigliadin

Small bowel biopsy 100% diagnostic

- villous atrophy on a gluten free diet

- Recurrence after a gluten challenge

Treatment: Gluten free diet for life



Prognosis: Strict diet - Normal growth – health

- 1% lymphoma

Causes of flat small intestinal

mucosa:

1. Celiac disease

2. Cow’s milk protein sensitivity

3. Post enteritis syndrome

4. Giardiasis

5. Tropical sprue

6. Soya protein intolerance

7. Autoimmune enteropathy

8. Protein energy malnutrition

Mucoviscidosis

Cystic fibrosis

 AR

 Defect:

Mucus secreted by exocrine glands is

abnormally thick and sticky due to defect in

chloride permeability which lead to failure in

maintaining the luminal hydration.

It is an obstructive lesion in which a duct or

airway passage is blocked by intra luminal

mucous and other protein.

60% presents before 1 year. 85% before 5

years

C.P. Most presented with failure to thrive

frequent foul smelling stocl

Rectal prolapse 18.5% by 1-2 Yr.





10% muconium illeus

- a plug of muconium in the terminal ileum

which lead to ischemic ulceration and

peritonitis

- delayed passage of muconium in neonate



10% Pancreatic fibrosis

Exocrine insufficiency  malabsorption

80% Recurrent chest infection

Atelactasis  Bronchiactasis 

Emphysema  Corpulmonal 

death



Rare Boys Azospermia 

infertility

Liver  obstructive jaundice

biliary cirrhosis

Gallbladder  Gall stones

Investigation:

1. 24 hour stool chymotripsin

2. True test for pancreatic function : by low

enzyme output from Pancreas, follow

stimulation by secretin and cholecytokinin

3. Sweat test. (Sweat chloride measurement)

 60 meq/L -------- diagnostic

If doubtful as is cases of edema , sweat

test should be repeated once edema subside



Treatment:

Enteric coated – acid resistant oral pancreatic

enzyme supplements

Diet high in protein, low fat or MCT diet

CYSTIC FIBROSIS

A.R.

Exocrine gland abnormalities



Electrolyte transport defect + inspissated mucous









Sweat Salivary Pancreatic Pancreas Lung Liver vas

Glands gland duct

deference



Bronchial



Obstruction

Obstruction

and infection



Defective Na + cl Defective HCO3 Pancreatic fibrosis Biliary duct

male

Absorption Secretion Obstruction

infertility

By gland Chronic

Obstructive

lung disease

Pancreatic Biliary cirrhosis

insufficiency



Cor pulmonale



mal absorption muconium

ilieus

Inflammatory bowel disease



A. Croh’s disease: Regional enteritis

Transmural inflammation with skip areas

Genetic predisposition



C/P Post prandial abdominal pain . ± diarrhea or constipation

weight loss fever

arthralgia /arthritis 2% Erythema nodosum

Investigations:  ESR Anemia  albumin  iron

: Proctoscopy

Double contrast colon X-ray

Rectal biopsy



Treatment: Enteral or parentral nutrition

Medicine - Prednisone

- Sulfasalazine (if colonic involvement)

- Azathoprine

- Cyclophosphamide

-70% surgical treatment

B. Ulcerative colitis

 Mucosal inflammation ---rarely involve muscularis layer

 Toxic mega colon



C/P bloody diarrhea + tenesmus

Complication Hge Mega colon

intractable symptoms

Arthalgia / arthritis

high risk of colonic cancer

Treatment: Enteral and parentral nutrition

medical: - Sulfasalazine oral



- hydro cortison enema

- systemic predisone

- Cyclo sporins



25% surgical treatment colectomy if mega colon

Thank You