o Retentive Involuntary overflow fecal incontinence secondary to chronic constipation and voluntary withholding of stool

Transcription

1 Encpresis Backgrund 1. Definitin: Inapprpriate siling in children withut any rganic cause Synnyms: Functinal fecal retentin Psychgenic megacln Idipathic cnstipatin 2. Tw subtypes: Retentive Invluntary verflw fecal incntinence secndary t chrnic cnstipatin and vluntary withhlding f stl Nn-Retentive Overflw fecal incntinence withut histry f cnstipatin r anatmical abnrmalities Pathphysilgy 1. Pathlgy Vicius cycle: Cnstipatin / hard stl Painful defecatin Retentin Mre cnstipatin Chrnic cnstipatin leads t stretching f intestinal walls and desensitizing f nerves Diminished nerve sensatins and sacrspinal defecatin reflex Lss f intestinal peristalsis and incmpetent internal anal sphincter leads t invluntary fecal incntinence 2. Incidence and prevalence 1-3 % in children 2.8% at age 4 yrs 1.5% at age 7-8 yrs 1.6% at age yrs Male > female 4-5x mre cmmn in bys Amng patients with hx f cnstipatin, encpresis ccurs amng 55% f bys and 35% f girls In tddlers (age 2-4), male t female rati is 1:1 By age 5 yrs, male t female rati is 3:1 By age 10 yrs, apprx. 1.6% f children still have encpresis Risk factrs Develpmental delay Enuresis Milestne changes Dietary switch t slid fd r cw's milk Encpresis Page 1 f

2 Tilet training Start f schl Behaviral prblems Oppsitinal Defiant Disrder Obsessive Cmpulsive Disrder ADD Tilet phbia Schl bathrm avidance Excessive parental interventin Early tilet training Sexual abuse hx Depressin Eating disturbance Mrbidity/mrtality Mrbidity: Subject f teasing / bullying Scial exclusin Lw self-esteem Depressin Mrtality Extremely rare May arise 2 t cmplicatins f chrnic cnstipatin (bwel bstructin, peritnitis) r due t depressin-related suicide Diagnstics 1. Histry Symptms: Onset / duratin f encpresis Stl frequency, caliber and cnsistency Siling interval Frequent inapprpriate siling hx "Paradxical diarrhea" (cnstipatin causing encpresis and verflw diarrhea) Cnstipatin histry Stl amunt depsited int underwear Painful bwels Stl pattern: Retentive: Cnstipatin Multiple stl intervals Lser stls Small caliber Nnretentive: Nrmal stl intervals Nrmal caliber Nrmal cnsistency Encpresis Page 2 f

3 Diet: Hx f inadequate dietary fiber- excessive intake f carbhydrates (cheese, pasta, starches) with lw-fiber meals Recent transitin frm breast milk t frmula Hx f excessive intake f cw's milk (>32z/ day)- mst cmmn cause f cnstipatin in children Medicatin hx: Antacids, Phenbarbital, Anti- chlinergics, Laxatives, Bismuth, Antidepressants, Sympathmimetics, Opiates Birth hx Delayed passage f mecnium (>24 hr age at first passage f mecnium) - suggests pssible Hirschsprung's disease r cystic fibrsis Past hx Infectins- UTI, Abdminal infectins Irritable bwel syndrme Inflammatry bwel disease Family hx Psychscial hx Relatinship with parents, peers, schl Precipitating events 2. Physical examinatin Height, Weight, & Grwth Curves Hx f delayed grwth and failure t thrive raises suspicin fr malabsrptive disrders (celiac disease, cystic fibrsis) r Hirschsprung's disease Skin: Pallr, dryness, reduced hair, fixed edema- suggestive f hypthyrid dx Abdmen: Bwel sunds- hypactive sunds may suggest ileus secndary t cnstipatin Distensin: If assciated with bilius emesis and pencil-thin stls, evaluate fr Hirschsprung's dx Palpable mass: Fecal mass maybe palpable in the LLQ/ suprapubic regin f patients with cnstipatin Palpable fecal mass with an empty rectum suggests Hirschsprung's dx Neplasms, such as lymphma, neurblastma, and pelvic teratma, that masquerade as chrnic cnstipatin symptms must be r/ in patients with palpable mass Rectal: Anus psitin (anterirly displaced anus, "ectpic anus," cntributes t cnstipatin) Anal fissures (cnsistent with cnstipatin; cntribute t fecal retentive behavir when recent / painful) Sphincter psitin, tne- lw suggests fecal retentin Vault size Encpresis Page 3 f

4 Digital exam necessary t evaluate fr rectal tne, distensin and fecal impactin; presence f impactin cnfirms functinal cnstipatin Reflex- presence f cremasteric reflex and anal wink suggests functinal cnstipatin; (absence f reflex suggests spinal crd prblem) Presence, absence, and texture f stl Empty rectum may suggest Hirschsprung disease Pelvic mass Retentive: Abdminal mass, distensin Wet clay-like stl in anal canal Full rectal vault r empty but large, capacius vault Nnretentive: Nrmal abdmen Nrmal rectal vault Back: Pigmented, hairy patch r abnrmal pit ver lumbsacral spine suggests sacral dysraphism Further wrk-up necessary t r/ neurpathic cnditins Neur: Reflex Delayed relaxatin phase f deep tendn reflex- suggestive f hypthyridism Tne Hyptnia may suggest muscular dystrphy Neurpathic cnditins lead t pr defecatry effrts Sensatin Use a wisp f cttn t test sacral sensitivity Reflex cntractin f external anal sphincter suggest apprpriate sacral sensrimtr integrity Perianal sensatin is absent with spinal disrders Spina bifida Myelmeningcele Spinal crd trauma r tethering Static encephalpathy 3. Diagnstic testing Labs- rarely indicated TSH- if presentatin suggestive f hypthyrid disrder (pr linear grwth, besity, enlarged fntanelles, bradycardia) UA- if hx f UTI r enuresis Calcium- if hx suggestive f hypercalcemia Lead- if hx suggests expsure r develpmental delay Serum tissue transglutaminase (TTG) and quantitative IgA if hx suggestive f pssible celiac disease Diagnstic Imaging Abdminal x-ray series: T rule ut bwel bstructin r if hx suggests Hirschsprung's dz Encpresis Page 4 f

5 X-ray cannt diagnse cnstipatin - must d digital rectal exam Anrectal manmetry: If hx suggestive f Hirschsprung's dz (nrmal internal anal sphincter relaxatin rules it ut) (83% sensitivity [+/- 2 SD = 63 93%]; 93% specificity [+/- 2 SD = 85 97%)] Barium enema: T evaluate fr Hirschsprung's disease (76% sensitivity [+/- 2 SD = 57-89%]; 97% sensitivity [+/- 2 SD = 91 99%]) Can als evaluate fr clnic strictures (necrtizing enterclitis) Rectal bipsy: Gld standard diagnstic test fr Hirschsprung's 93% sensitivity [+/- 2 SD = 77 98%] 100% specificity [+/- 2 SD = %] Indicated in cnstipated patients wh have empty rectum n exam r ther findings suggestive f Hirschsprung's disease Lack f ganglin cells n bipsy is highly suggestive f Hirschsprung's Hyperganglinsis with increased acetylchlinesterase suggests intestinal neurnal dysplasia Differential Diagnsis 1. Retentive: Functinal- mst cmmn cause f fecal retentin Anatmical- anal fissures, anal stensis, trauma, pst-surgery, perianal infectin (strep, abscess, etc.) Neurgenic- intestinal pseud bstructin, spinal crd disrder, cerebral palsy, pelvic tumr, Hirschsprung's disease Neurmuscular disrders- muscular dystrphy Cnnective tissue disrders- Amylidsis, SLE, Sclerderma Metablic- hypercalcemia, hypkalemia, cystic fibrsis, hypthyrid, lead pisning, diabetes mellitus, celiac disease Drugs- Antichlinergics, Antihypertensives, Antacids, Sucralfate, Opiates 2. Nn retentive: Nnrganic (99%) IBD Cngenital neurlgical disrders (spinal crd tumr, lipma) Pst surgical anal sphincter trauma Acute Treatment 1. Retentive Medicatins: Disimpactin phase <1 wk Relieve impactin thru ral r rectal cathartics; rarely, manual disimpactin is indicated Stl sfteners: mineral il, lactulse, plyethylene glycl Laxatives: Milk f Magnesia, Senna, Dulclax, Sdium phsphate enemas Encpresis Page 5 f

6 2. Nn-retentive Sme experts prefer ral medicatins ver rectal medicatins Mnitr fecal prductin thru parental reprt, stl diaries Success f catharsis based n abundant fecal prductin and decreased siling episdes Pst disimpactin, immediate fllw-up is recmmended t discuss maintenance therapy Maintenance phase (2-12 ms) Cntinue treatment with lw-dse laxatives fr several mnths after initial disimpactin t maintain daily defecatin Titrate dses t btain 1-3 sft, easy-t-pass bwel mvements/ day Medicatin withdrawal phase After mnths f retraining bwel with cathartics, withdraw medicatin nce patient's bwel can wrk apprpriately n it's wn Patients must be having at least 1 bwel mvement/ day withut encpresis in rder t stp meds Mdify tilet habits: Encurage child t Sit n tilet fr a minimum f 10 minutes 2 times per day, ideally after meals, with a timer Flexin f hips helps t pen up rectal wall Ft stls maybe used t increase abdminal pressure Schedule prmpted tilet sits Begin with shrt 30 sec sits Gradually increase t 5 minute sits 3-5/day Gal is t assciate tilet sitting with enjyable activities Prvide pleasant and relaxed atmsphere with plenty f parental attentin Diet: Prvide adequate daily intake f high-fiber, fruits, vegetables Daily recmmended fiber intake is age f child (in years) plus 5 grams Behaviral mdificatin Regulate tilet sitting behavir- give psitive incentives fr bwel mvements in the tilet Schedule prmpted tilet sits Parents shuld stp pressuring patients with reminders, lectures, inquiries abut bwel mvements Change siling immediately- emphasize that parents shuld use this pprtunity as a neutral, timely interactin Dietary mdificatin Ensure well-frmed, sft stls with high fiber in meals Stp all medicatins: laxatives, stl sfteners Further Management 1. Retentive Mre than 30% will still be impacted 1 wk int treatment Repeat abdminal/ rectal exam Encpresis Page 6 f

7 If n bwel mvement fr 48 hr, increase stl sfteners 2. Nn-retentive: Requires mre intensive treatment N stl sfteners needed Minimize pressure frm parents fr a child t be tilet trained Encurage parents t avid punishing child fr siling Prvide psitive incentives: praise, hug, sticker, giving them their favrite treats Lng Term Care 1. Gal is t have 1-3 easy-t-pass bwel mvements every day (may take years t accmplish) 2. Prvide extensive parental educatin 3. Emphasize behaviral mdificatin 4. Encurage reward system t imprve patient cmpliance 5. Wean laxatives as patient's bwel frequency stabilizes Must be stable fr at least 6 mnths prir t decreasing laxatives Fllw-Up 1. Return t ffice Regular and frequent mnitring necessary t prevent recurrences Children with impactin must be evaluated within 1 wk int treatment RTC shuld be n a mnthly basis initially Mnitr stl recrds every 3-4 mnths, repeating physical exam when necessary Adjust medicatin, diet regimen as needed based n clinical prgress 2. Refer t specialist Gastrenterlgist: If ral medicatin regimen fails t imprve disimpactin If systemic symptms r grwth failure cmplicating encpresis Psychiatrist r psychlgist: Refusal t sit n tilet by patient >5 y Refusal t take meds Nn retentive encpresis and >8 y Depressive symptms Disturbed parent-child relatinship 3. Admit t hspital Majrity f cases may be managed as utpatient Admit if cmplicatins arise frm chrnic cnstipatin Bwel bstructin Histry f anatmical anmalies Prgnsis 1. Retentive: 99% cure with pain-related impactin 70% cure with psychgenic impactin: may need further evaluatin by psychiatrists Encpresis Page 7 f

8 2. Nn retentive: 90-95% cure if <5 yr histry Preventin 1. Treat nn-encpretic cnstipatin prmptly 2. Educate and instruct parents t increase laxatives if child ges >2 days withut bwel mvement 3. Vigrus interventin necessary if reimpactin ccurs: duble laxatives, enema, r suppsitries 4. Emphasize scheduled 10 minute tilet sitting 2/day t relieve early impactin References 1. Hekelman, A. Rbert, ed. Primary Pediatric Care, 4th editin, 2001; pages Rudlph, D. Clin and Rudlph M. Abraham. Rudlph's Pediatrics, 21st editin, 2003, chapter 17, pages Kuhn, R. Brett. "Treatment Guidelines fr Primary Nnretentive Encpresis and Stl Tileting Refusal" American Family Physician. April 15th, Behrman, E. Richard. Nelsn Textbk f Pediatrics, 17th editin, chapter 20, page Lake, M. Alan. "Chrnic Abdminal Pain in Childhd: Diagnsis and Management" American Family Physician. April 1st, Arce, A. Daisy, Ermcilla, A. Carls and Csta, Hildegard. "Evaluatin f Cnstipatin" American Family Physician. June 1st, 2002; pages Biggs S. Wendy and Dery, H. William. "Evaluatin and treatment f cnstipatin" American Family Physician, Feb 1st, Taylr, B. Rbert. Family Medicine, Principles and Practice, page "Clinical manifestatins and evaluatin f encpresis." Online. dtitle=1~6 10. "Treatment f chrnic functinal cnstipatin and fecal incntinence in infants and children" Online. ~9&surce=search_result 11. "Md disrder: Dysthymia disrder" Online. Authr: Smitha Rajasekhar, MD, Adventist Hinsdale Hspital FMR Editr: Perry Brwn, MD, Idah State University FPR Encpresis Page 8 f