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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.

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CONSTIPATION

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  1. CONSTIPATION Dr. Soad Jaber 2009

  2. 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

  3. 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

  4. Constipation: • Delay or difficulty in defecation that has been present for two weeks or longer. is associated with anal and abdominal discomfort. • Full rectum

  5. Functional Constipation: Is a voluntary withholding of stools Starts after the neonatal period Usually develop after passage of painful bowel movement.

  6. 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.

  7. Types of Encopresis: • A)RETENTIVE encopresis with constipation and overflow incontinence.2/3 B)Non RETINTIVE encopresis: without • constipation and overflow.1/3 • OR :1ry from infancy occur with global developmental delay and enuresis. • 2ry:after successful toilet training occur with psychosocial stress and mismanagement

  8. 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

  9. Neurogenic Soiling: Soiling which occur due to neurological abnormalities: Spinal bifida Paraplegia Myelomengiocel

  10. Causes of Constipation: • 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)

  11. 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<Vincristine,vit D intoxication,Lead)

  12. Metabolic disorders(Hypokalemia,hypercalcemia,hypotghyroidism,D.M) • Intestinal disorders:(celiac disease,cow milk protein intolerance,meconium ileus,inflammatory bowel disease,tumour) • Connective tissue disordersSLE,sclerderma) • Psychiatric diagnosis(Anorexia nervosa)

  13. 2. Organic Causes • Hirschsprung’s disease *Clinical clues • Delayed muconium passage > 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

  14. 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

  15. Complication of stool retention • Impaction • Abdominal pain • Overflow diarrhea  leakage around the fecal mass • Anal fissure • Rectal bleeding • Urinary tract infection

  16. 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

  17. 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

  18. Medical • Hypertonic phosphate enemas daily or every other day for 1 week. • 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. • Ensure that the child has sufficient fluid and fiber in the diet • Bulk type of softness (Metamucil) maybe administered as the dose of mineral oil is tapered. • Lactulose, senna, may have to be prescribed to break the vicious cycle of fecal retention and pain

  19. 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

  20. 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.

  21. 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

  22. Goals: • Empty Rectum Clean out retained stool Enema Suppositories Senakot Bowel cleaning

  23. 2. Bulky stool High fiber diet (bran)

  24. 3. Improve habits Regular time of toilet after feed Stars chart Position- squatting De emotionalize home environment

  25. Functional Constipation: WHY MAY THE TREATMENT FAIL ?! • Inadequate clean out  suppositories • Inadequate dosage of medication • On and off approach: Intermittent use of medication

  26. Malabsorption Objectives: • Digestion • Definition • Identify major causes of malabsorption • Know to work up for malabsorption

  27. Malabsorption Digestion • Stomach ------- breakdown ingested food by rhythmic contraction gastric acids. • Small bowel---- Intestinal secretion  digestion. *Brush Border

  28. 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

  29. Malabsorption SyndromesMalabsorptive 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

  30. 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

  31. II. Malabsorption according to substances: • Fat Celiac disease Cystic fibrosis OTHERS: Giardiasis Congenital intestinal malformation Crohn’s disease Biliary atrasia Liver cirrhosis

  32. 2.Carbohydrate Glucose -galactose transport defect Genetic Lactose (Primary lactase deficiency) Sucrose (Congenital sucrase – isomaltase deficiency) Secondary celiac disease any chronic diarrhea

  33. 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

  34. III. Malabsorption according to site of defects. • 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

  35. 2. None mucosal Pancreatic disease ------ cystic fibrosis Bile losses ---- bacterial overgrowth  deconjugation of bile acids  Cholestasis Lymphatic obstruction------ lymphagiactasia A Beta–lipo proteinemia

  36. 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

  37. Examination Growth chart Pallor --- Iron, folate Clubbing CF, IBD, CD Chest problem CF Distended abdomen CD Muscle hypotonia + wasting Nappy rash Rectal examination (prolapsed)

  38. Laboratory investigations: • 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)

  39. 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

  40. 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

  41. 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)

  42. 3. Others • Sweat chloride test • Hydrogen breath test • D-xylose test • Schilling test (Vit B12)

  43. 4. Diagnostic Procedure: • 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

  44. 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

  45. 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

  46. 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

  47. 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.

  48. Celiac disease • Allergy to Gliaden portion of gluten (wheat, Rye, Oats or barley) • Screening antibodies Antigliadin IgA, Anti reticulin, Anti endomyseal EMA

  49. 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

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