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Constipation & Diarrhea

Constipation & Diarrhea. March 4, 2010. Objectives. Learn an approach to treating constipation in the Emergency Room and on discharge Discuss when “constipation” needs further workup Diarrhea-discuss the common and important ED presentations. True or False.

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Constipation & Diarrhea

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  1. Constipation & Diarrhea March 4, 2010

  2. Objectives • Learn an approach to treating constipation in the Emergency Room and on discharge • Discuss when “constipation” needs further workup • Diarrhea-discuss the common and important ED presentations

  3. True or False • Correction of constipation has been shown to diminish enuresis • Correction of constipation has been shown to decrease the frequency of UTI’s • Fecal soiling is associated with severe functional constipation • Constipation can be a cause of rectal prolapse • On digital rectal exam, no stool in the rectal vault is consistent with functional constipation

  4. True or False • Vomiting can be a sign of Hirshsprung’s • Vomiting can be a sign of functional constipation • Celiac disease can present as constipation • Constipation is the first symptom of botulism

  5. Few more quick facts • When is the 1st stool of a neonate normally passed? • Which chemotherapy agent causes constipation?

  6. Definitions • Constipation • Functional Constipation

  7. Definitions • Constipation • Delay or difficulty in defecation, present for >2 weeks • Functional Constipation • Constipation without objective evidence of a pathologic condition

  8. Case 1 • 2 month baby, term, formula fed • Having 4-5 bowel movements/week • Grandma thinks something is seriously wrong because her other grandchild has 4-5 bowel movements/day • What do you do?

  9. Normal Defecation Pattern

  10. Normal Defecation Pattern NASPGHAN clinical practice guidelines

  11. Normal Defecation Pattern NASPGHAN clinical practice guidelines

  12. Approach to Constipation • What is your approach???

  13. Approach to Constipation • Are there any red flags?

  14. Approach to Constipation • Red flags • Fever • Emesis • Bloody diarrhea • FTT • Anal stenosis • Tight empty rectum • Delayed passage of meconium • If yes….need to investigate further

  15. Approach to Constipation • No red flags=functional constipation • Is there fecal impaction? • Yes: disimpact • Oral or rectal meds • Usually 2-3 days required • No: Treat as outpatient • Education, diet, oral meds

  16. Approach to constipation • Treatment effective • Yes: maintence therapy 4-6 months • No: Bloodwork • T4, TSH • Celiac screen • Lead • Calcium • If above workup is negative, and child still constipated, refer to GI • But may want to refer for sweat chloride & rectal bx

  17. What about abdominal x-rays? • Not needed if rectal exam reveals large amounts of stool • Sens & PPV >80% • If child is obese or refuses the rectal exam, the AXR is reliable in determining fecal retention • If used in combination with DRE • sens 92% & PPV 94% NASPGHAN clinical practice guidelines

  18. Case 2 • 1 month asian male, term, with 12h hx of constipation • Prior to presentation, had had 4-5 BM/day • Breastfed, feeding less well at last 2 feeds • No emesis • Had passed meconium within first 24h • Neonatal screen Neg for CF and hypothyroid • O/E: • alert, slightly fussy, vitals stable • distended abdo, +BS • No anal fissure • Palpable firm stool in rectum

  19. Case 2 • AXR

  20. Case 2 • AXR

  21. Case 2 • Glycerin supp-resulted in dry, crumbly stool in diaper • Attempted enema-came out immediately • Manual disimpaction-able to remove dry hard stool, with overflow liquid seepage • After disimpaction, fed well, abdomen softer • Arranged for F/U in Urgent Peds for further W/U (hirshsprung, CF, hypothyroid)

  22. Case 2 • Returned to ED the following afternoon • Tachypnic • Repeat AXR

  23. Case 2

  24. Case 2 • Intubated due to respiratory distress • Went up to OR for laparotomy…..with pre-op suspicion of volvulus • Post op dx: Inspissated stool • Workup all negative • Sweat chloride, Hirshsprung’s, thyroid

  25. Case 2: Take home message • Be cautious in diagnosing and discharging a 1 month old with constipation!

  26. Case 3 • 3 month male with distended abdomen & poor feeding • No emesis • Passing stool 2-3 times/day • Febrile in ED (38.8) • What do you want to do? • NB question on history: is the stool liquid? (ie overflow incontinence) • NB finding on exam: tight anal sphincter with no stool in rectum

  27. Hirshsprung Disease • Most common cause of lower intestinal obstruction in neonates • Rare cause of intractable constipation in toddlers & school age children • Diagnosed after age 3 in 8-20% of pts • Absence of ganglion cells in the myenteric & submucous plexuses of the distal colon • Sustained contraction of the aganglionic segment

  28. Hirshsprung Disease • Enterocolitis • Fever, abdo distension, explosive bloody diarrhea • Occurs at age 2-3 months • 20% mortality • Greatest risk factor is delayed diagnosis of Hirshsprung’s

  29. The “don’t want to miss” causes of constipation • Hirshsprung Disease • Cystic Fibrosis • Botulism • Hypothyroid • Imperforate anus • Sacral teratoma • Sexual abuse • Celiac Disease

  30. Botulism • Initial symptom of botulism is constipation • Lethargy and feeding difficulties follow • P/E: • Decreased DTR, decreased suck & gag • Poorly reactive pupils & Ptosis • Oculomotor palsies • Facial weakness • Dx: Identify C. botulinum spores & toxin in stool* • Tx: Admit! 50-77% require intubation • Baby BIG

  31. Treatment of Constipation • Depends on age • If <3 months, should have F/U with a Pediatrician • Consists of • “rescue therapy” • maintenance therapy

  32. Acute treatment (>1 year) • Fleet Enema • Pediatric 66mL, Adult 133mL • Once >2 yrs, use adult enema • Onset 2-5 minutes • Side effects: • Hyperphosphatemia • Use with caution in renal failure • Osmotic effect in the small intestine • draws water into the gut lumen, produces distension, promotes peristalsis and evacuation

  33. Maintenance Treatment(>1 year) • PEG 3350 • Osmotic Laxative • Dose 1g/kg/d (Max 17g) • Onset in 1-3 days • Side effects (minimal): • bloating, cramping, diarrhea, flatulence, nausea • Contraindications • GI obstruction, ileus, bowel perforation, toxic colitis, megacolon

  34. Evidence for PEG 3350 • RCT, double blind • 100 patients (aged 6 months-15 years) • After fecal disimpaction, received either PEG or Lactulose • Primary outcomes: • defecation and encopresis frequency/week • successful treatment after eight weeks • Secondary outcomes: • Side effects after 8 weeks Gut. 2004 Nov;53(11):1590-4.

  35. Evidence for PEG 3350 • Success defined as: • defecation frequency > 3/week • encopresis < once every 2 weeks • Results • Success was significantly higher in the PEG group (56%) compared with the lactulose group (29%) • PEG 3350 patients reported less abdominal pain, straining, and pain at defecation than children using lactulose

  36. Evidence for PEG 3350 CONCLUSIONS: • PEG 3350 compared with lactulose provided a higher success rate with fewer side effects • PEG 3350 should be the laxative of first choice in childhood constipation

  37. Treatments to avoid • Mineral oil (if <1 yr, use with caution if <3) • Lipoid pneumonia if aspirated • Phosphate enemas (if <1 year) • Can use glycerine suppository • Stimulant laxatives (long term) • Senekot • Dulcolax

  38. Case 4 • 2 year female with 4 day hx of constipation & 8 cm rectal prolapse • Has just started toilet training • What are you going to do?

  39. Case 4 • Other history • Has 2-3 BM/week with ++straining • Fecal soiling present • Term, passed meconium on day 2 of life • Was admitted to hospital at 18 months with pneumonia • O/E • Weight & height at 5th percentile

  40. Case 4 • Other history • Has 2-3 BM/week with ++straining • Fecal soiling present • Term, passed meconium on day 2 of life • Was admitted to hospital at 18 months with pneumonia • O/E • Weight & height at 5th percentile

  41. Case 4 • What is your immediate treatment? • What is the diagnosis? (top 3)

  42. Case 4 • What is your immediate treatment • Reduce protrusion (pressure with warm compress) • Start pt on stool softeners • Surgery in refractive cases • What is the diagnosis? (top 3) • Cystic Fibrosis • Chronic constipation • Meningocoele

  43. True or False • Correction of constipation has been shown to diminish enuresis • TRUE

  44. True or False • Correction of constipation has been shown to decrease the frequency of UTI’s • TRUE

  45. True or False • Fecal soiling is associated with severe functional constipation • TRUE

  46. True or False • Constipation can be a cause of rectal prolapse • TRUE but….need to also consider other etiologies • Cystic Fibrosis • Meningocoele • Enterobius vermicularis (pinworm) • Ehlers-Danlos • Ulcerative colitis • Pertussis

  47. True or False • On digital rectal exam, no stool in the rectal vault is consistent with functional constipation • FALSE

  48. True or False • Vomiting can be a sign of Hirshsprung’s • TRUE

  49. True or False • Vomiting can be a sign of functional constipation • FALSE

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