Constipation- more than Movicol? PATRICK NEARNEY GPSI PAEDIATIRICS
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1 Constipation- more than Movicol? PATRICK NEARNEY GPSI PAEDIATIRICS
2 Learning Points How to rule out an underlying cause for constipation How to diagnose and treat faecal impaction How to manage encopresis Learn about the many ways in which constipation can present How to assess Chronic Abdominal Pain in Children How to do a growth assessment in 30 seconds Learn about the Role of Specialist Paediatric Continence Nurse
3 Case 1 4 year old boy Mum says always been constipated Bowels open large stool which blocks the toilet every 3 days In between gets liquid in the underwear Doesn t seem to notice comes home in soiled pants GP colleague started movicol but increased soiling so mum has stopped it. How would you Assess further? What is the most likely diagnosis and what would be your management?
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7 Encopresis and Soiling In the UK separate definitions are used for encopresis and soiling, in contrast in the USA the term encopresis is used to describe any regular passage of stool into underwear. (The terms non-retentive and retentive encopresis are sometimes used) In the UK encopresis is described as the passage of a normal stool in a socially inappropriate or unacceptable place (Non-retentive encopresis) Soiling is described as the involuntary passage of fluid or semisolid stool into underwear (most commonly as a result of overflow from a faecally loaded rectum) (Retentive encopresis)
8 Encopresis and Soiling Although parents may find it frustrating, soiling is very rarely thought to be caused by a child misbehaving. They usually can't help it and some children may not even realise they've had an accident. Children who have this problem may feel ashamed, guilty, frustrated or angry, and may act secretively to try to hide the problem. Most children who soil their pants are severely constipated. They may ignore the urge to go to the toilet and "hold on" to avoid the pain of passing stools. This leads to faecal impaction when a large, solid stool becomes stuck in their rectum (back passage) and begins to stretch and weaken the surrounding muscle walls. Watery stools then leak out from around this blockage.
9 Case 2 6 year old boy 1 year history of central and lower abdominal pain Pain occurs after eating and lasts for approximately 15minutes Active boy- who eats well and is growing normally No change in bowel habit Initially his symptoms were worse at school and aunties house but now it can occur anywhere FBC UE LFT CRP normal On examination BMI was 18.3
10 Presentation of symptoms Common things present commonly and common things present uncommonly 3 main diagnoses to consider in Chronic Abdominal pain in children Stool diary often needed to diagnose constipation Growth Assessment essential for chronic abdominal pain Affect on daily activities is used to class severity
11 Which of the following can be a initial presentation of Constipation? Abdominal Pain Rectal Bleeding Rectal Prolapse Recurrent UTI s Enuresis Vulvovaginitis
12 Chronic Abdo Pain With Alarm features Without Alarm Features Investigate and refer Exclude Constipation Coeliac Screen Manage as functional Abdominal Pain
13 Management of Functional Abdominal pain Using Consultation Skills for a Bespoke Management Plan Ideas Might be food allergy food diary/ short term exclusion Coeliac screen? Concerns Physical disease Expectation Extensive investigati ons Psychosocial Issues Missing School Explain- common and if no alarm symptoms and growing then unlikely anything serious GA needed for endoscopy Blood tests rarely helpful. Letter to school Stand by medication
14 5 year old girl with BMI 18 a) Underweight b) Healthy Weight c) Overweight
15 BMI centiles
16 Weight gain Average weight (Age +4) x2 Approx 2kg per year mid childhood
17 Linear Growth Velocity Mid childhood age 3 to cm per year Prepuberty Nadir 5cm per year
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