Constipation

7.13 Constipation



Bruce Fasher




Essentials



1 It is important to understand the physiology and development of gut transit to recognise the normal (often regarded as abnormal).

2 Constipation is a common reason for children to present to EDs with abdominal pain.

3 Management depends on the child’s age and whether the problem is acute or chronic.

4 The patient’s and parents’ real concerns need to be acknowledged.

5 Issues to be addressed include:
• natural history;

• the aims of treatment (empty the bowel and establish pharmacological rhythm and then wean to biological rhythm);

• the likely duration of treatment;

• the anticipated setbacks;

• the need for a coordinator clinician (normally unavailable in an ED).

6 Treat from the top, once at night and titrate the dose according to the response. Avoid treatment per rectum if at all possible, to draw attention away from any anal obsession to achieve bowel actions.

7 Be able to refer to a resource who is known to be interested in managing the condition and to ensure appropriate ongoing review and support.


Introduction


Constipation in childhood engenders in clinicians unwarranted anxieties about management. Defining terms and understanding normal physiology and its variants, the frequent blurring in paediatric medicine between physical and emotional factors and their impact on normal development along with evidence-based data can provide the clinician with an algorithm for management.


Management varies according to age and whether constipation is acute or chronic. The emergency department (ED) is a difficult place from which to manage constipation, especially chronic constipation, for success requires ongoing maintenance therapy and contact with a committed and interested clinician. This is best achieved through the child’s local doctor, with input from a sympathetic paediatrician in difficult cases if deemed appropriate.1,2



Definitions



Constipation is delay or difficulty in defecation, sufficient to cause significant distress.

Encopresis is the passage of a normal stool in an abnormal place.

Soiling is the frequent involuntary passage of loose or semi-loose stools in clothing. This is usually overflow incontinence as the liquid stool escapes around an impacted rectal faecolith.


Pathophysiology


The rectum and anal canal have two tasks, to store faeces temporarily and to evacuate at a socially convenient time. The distending rectum evokes a wave of contraction with inhibition of the smooth muscle tone of the internal anal sphincter, resulting in a sensation of the urge to defecate. An urgent desire to defecate occurs as the stool stretches the sensitive zone of the upper anal canal. This urge is overcome by the voluntary contraction of the external sphincter and the levator ani muscles. Eventually the rectum habituates to the stimulus of the enlarging faecal mass and the urge to defecate subsides. With time this retentive pattern can become automatic.


It is understandable, therefore, that the child who is afraid to use the non-private, wet, smelly school lavatory, and allows his rectum occasionally to overcome the external sphincter, as he is relieved to arrive home, albeit with ‘poo in the pants’ – is really a normal variant rather than true encopresis.


There is a wide variation of physiology and normal development as can be seen in the age range of successful potty training. To produce a stool at will is one of the child’s first major achievements and most gain satisfaction from framing their success in a pot. If too much persuasion is provided, especially if full control has never been attained, the child’s profound disappointments are compounded by disapproval and hostility from the parents. Like most adults, most children seek solitude to defecate.



Management basics



Be interested. The patient has often been pushed from pillar to post, with a quick fix, and reviewed in 3 months. Recognise that the parents and the patient have a concern, which can be the cause of major family dysfunction.

Endeavour to treat from the top, orally, rather than continue to direct attention to the rectum and anus with suppositories and enemas. The exception is when a fissure needs managing with ointment or Xylocaine ointment if defecation can be anticipated.

Develop a pharmacological armamentarium of stool softeners or osmotic aperients. Stimulants (e.g. senna) may cause abdominal discomfort with colic in infants.

Be aware that ongoing management by a single interested clinician is desirable as the constipation will often relapse, and gains are often small (three steps forward, two steps back).

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Sep 7, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Constipation

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