CONSTIPATION. Atan Baas Sinuhaji

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1 CONSTIPATION Atan Baas Sinuhaji Sub Division of Pediatrics Gastroentero-Hepatolgy Department of ChildHealth,School of Medicine University of Sumatera Utara MEDAN

2 DEFECATION REGULAR PATTERN CONSTIPATION GOOD HEALTH BACKUP OF STOOLS ACCUMULATION OF TOXIN IN THE BLOOD

3 DEFINITION OF CONSTIPATION VARIES AMONG INDIVIDUAL HARD LARGE INFREQUENT PAIN OR STOOLS STOOLS STOOLS PRESSURE WHILE STOOLING

4 CONSTIPATION FREQ. DEFECATION - HARD, DRY STOOLS - DIFFICULT / PAIN - INCONTINENCE = SOILING = ENCOPRESIS

5 FREQUENCY OF DEFECATION NORMAL = 2 X / DAY- 1 X/2DAYS ABNORMAL < 1 X / 2 DAYS

6 SOILING WITHOUT CONSTIPATION WITH CONSTIPATION MENTAL RETARDATION

7 CLASSIFICATION 1. ACUTE / CHRONIC ( 3 MONTHS ) 2. SEVERITY 3. ORGANIC / IDIOPATHIC 4. PATHOGENESIS 5. ANORECTAL DYSFUNCTION (+)/(-) 6.OBSTRUCTIVE / FUNCTIONAL 7. CONGENITAL / ACQUIRED

8 ORGANIC ENDOCRINE AND METABOLIC OTHERS ( faulty diet or bowel habit, long distance travel ) 2.NEUROGENIC 3.OBSTRUCTIVE LESION 4.FUNCTIONAL ABNORMALITIES OF MUSCLE FUNCTION (eg.colonic ANORECTAL OR PELVIC FLOOR PSYCHOLOGICAL DISEASES

9 Rome III Functional constipation At least once per week for at least 2 months before diagnosis. Must included 2 of following criteria defecations / wk 2. 1 episode of fecal incontinence/wk 3. Retentive posturing or excessive volitional stool retention 4. History of painful or hard bowel movements 5. Presence of a large fecal mass in the rectum 6. History of large diameter stools which can obstruct the toilet

10 RECTAL FILLING DEFECATION PROPULSION OF RECTAL CONTENTS

11 PROPULSION OF RECTAL CONTENTS - DISTENTION - CONTRACTION - RECTAL PRESSURE - URGE TO DEFECATE - STRAINING - RELAXING THE ANAL SPHINCTER

12 ANAL SPHINCTER INTERNAL EXTERNAL INVOLUNTARY VOLUNTARY

13 INCREASING INTRA ABDOMINAL INHIBITION IN MUSCLE ACTIVITY OF THE PELVIC ANORECTAL ANGLE INCREASE 80 0 TO 140 O DUE TO RELAXATION OF THE PUBORECTAL MUSCLE

14

15 NORMAL DEFECATION INVOLVES SYNCHRONIZED INVOLUNTARY AND VOLUNTARY FUNCTIONS

16 CONSTIPATION IMPAIRED RECTAL FILLING IMPAIRED RECTAL PROPULSION

17 IMPAIRED RECTAL FILLING IMPAIRED PERISTALSIS OBSTRUCTION DRUGS HORMONAL -SPASMOLYTIC HYPOTHYROIDISM -CODEIN MORBUS HIRSCHSPRUNG

18 IMPAIRED RECTAL PROPULSION 1. PERISTALSIS 2. OBSTRUCTION 3. SENSATION (SPINAL CORD LESION, etc) 4. RELAXATION OF ANAL SPHINCTER (ANAL FISSURE, STENOSIS) 5. ABNORMALITY OF ABDOMINAL/ PELVIC WALL 6. ABNORMALITY OF AUTONOMIC & CORTICAL CONTROL 7. ABNORMALITY OF ANAL CANAL

19 PRECIPITATING EVENT UNEXPELLED STOOLS FUTHER STOOL RETENTION & SOILING RECTAL DISTENTION PAIN AND WITH HOLDING DEPRESSED ANORECTAL REFLEX ANAL FISSURE NO URGE TO STOOL HARD STOOLS WATER REABSORBSTION

20 WITHHOLD STOOLS =PAIN FISSURE =LACK OF TIME =POOR HYGIEN =NET ALLOWED SCHOOL

21 CONSEQUENCES 1. VOMITING 2. ABDOMINAL PAIN 3. ABDOMINAL DISTENTION 4. PAIN TO DEFECATE 5. RECTAL BLEEDING ANAL FISSURE 6. ANOREXIA 7. ABDOMINAL MASS RETENTION OF URINE 8. CHRONIC - PCM - MEGACOLON

22 MEGACOLON CONGENITAL AGANGLIONIC = M. HIRSCHSPRUNG IDIOPATHIC = ACQUIRED = CHRONIC IDIOPATHIC CONSTIPATION STOOLS MEGACOLON PARADOXAL DIARRHOEA Ganglion (-) Peristalsis Obstruction BARIUM IN LOOP External Anal Sphincter INCONTINENTIA ALVI

23 MEGACOLON IDIOPATHIC= ACQUIRED CONGENITAL 1. ONSET 2-3 YEARS 1 ST DAY 2. SOILING (+) (-) 3. PARADOXAL (-) (+) DIARRHOEA 4. PCM (-) (+) 5. ABD. DISTENTION (+) (++) 6. ANAL SPHINCTER LOOSE TIGHT 7. RECTAL AMPULLA FULL EMPTY 8. ENTEROCOLITIS (-) (+) 9. TREATMENT MEDICAL SURGERY

24 M. HIRSCHSPRUNG DIAGNOSIS IRRIGATION FULMINANT ENTEROCOLITIS OPERATION COLOSTOMY DEATH DEFINITIVE (6-12 MONTHS)

25 CHRONIC IDIOPHATIC CONSTIPATION 1. EVACUATION OF FIRM STOOLS (FECAL DISIMPACTION) MgSO 4 IRRIGATION etc 2. MAINTENANCE 1. DIETARY MANIPULATION FIBERS >>> 2. TOILET TRAINING 3. DRUGS : TAP WATER >>> a. SPASMOLYTIC (-) b. LAXANTIA : lactulose polyethylene glycol c. ANAEROB BACTERIAL: metronidazole

26 Behaviour therapy toilet training Start after the age of two 5-10 minutes Learn to take time to defecate Learn to push down After each meal gastro - colic reflex Reward

27 OLD PARADIGM CHRONIC CONSTIPATION IS A BEHAVIOUR/LEARNING DISORDER Behaviour / Learning COMMON CAUSES = Adverse life event = Defiant behaviour = Intellectual disability ( plus rare organic causes ) = Cystic fibrosis = Hirschsprung s Disease

28 NEW PARADIGM CHRONIC CONSTIPATION IS AN ORGANIC OR A BEHAVIOUR/LEARNING DISORDER COMMON CAUSES Behaviour / Learning Organic = Adverse life event = Colonic dysmotily = Defiant behaviour = Outlet obstruction = Intellectual disability ( plus rare organic causes ) = Cystic fibrosis = Hirschsprung s Disease

29 IN 70 %AFFECTED CHILDREN,CONSTIPATION RESPONS WITHIN 2 YEARS OF DIAGNOSIS TO MEDICAL THERAPIES OR BEHAVIORAL MODIFICATION THE REMAINING CHILDREN ARE CLASSIFIED WITH CHRONIC TREATMENT- RESISTANT CONSTIPATION

30 CHRONIC TREATMENT-RESISTANT RESISTANT CONSTIPATION IDIOPATHIC ORGANIC FUNCTIONAL

31 FUNCTIONAL COLONIC TRANSIT TIME NORMAL ABNORMAL HOLD UP AT ANO-RECTUM FUNCTIONAL FECAL REENTION SLOW TRANSIT CONSTIPATION

32 SLOW TRANSIT CONSTIPATION DELAY IN COLONIC TRANSIT TIME INTRACTABLE CONSTIPATION NOT RESPONSE TO LAXATIVE DIET CHANGE IN LIFE STYLE

33 CONCLUSIONS CONSTIPATION COMMON COMMON PROBLEM DURING CHILDHOOD ACUTE FORM EASILY CORRECTED ACUTE FORM NOT PROPERLY TREATED CYCLE UNEXPELLED FECES BEGINS COMPLICATION CHRONIC CONSTIPATION IS AN ORGANIC CAUSES NOT ONLY BEHAVIOUR/LEARNING DISORDER

34 SLOW TRANSIT CONSTIPATION DELAY IN COLONIC TRANSIT TIME TERIMA KASIH INTRACTABLE CONSTIPATION NOT RESPONSE TO LAXATIVE DIET CHANGE IN LIFE STYLE

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