The Straight Poop

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The Straight Poopor how I learned to stop
worrying and love the bomb

• Michael F. Ziegler, MD
• Assistant Professor
• Departments of Pediatrics and Emergency Medicine
• Emory University

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Constipation

• Occurrence
• 3 of visits to Pediatricians
• 25 of visits to Gastroenterologists
• Definitions
• Difficult or infrequent bowel movements
• Painful defecation
• Passage of hard stools
• Sensation of incomplete evacuation of stool

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North American Society for Pediatric
Gastroenterology Hepatology and Nutrition
(NASPGHAN)

• Constipation
• Delay or difficulty in defecation, present for
  two or more weeks and sufficient to cause
  significant distress to the patient
• Baker, et al J Pediatr Gastroenterol Nutr 1999 29

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Paris Conference

• Constipation
• Two or more of the following occurring over the
  preceeding 8 weeks
• Frequency of BMs lt3/week
• gt1 episode of fecal incontinence/week
• Large stools in the rectum or palpable on the
  abdominal exam
• Passage of stools so large they obstruct the
  toilet
• Retentive posturing and withholding behavior
• Painful defecation
• Benninga, et al J Pediatr Gastroenterol Nutr
  200940

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Colon Physiology

• Muscular contractions propel and mix contents
• Increased on waking and after meals (The
  Gastrocolic Reflex)
• Reabsorption of water and electrolytes mostly in
  cecum and transverse colon
• Primarily water follows osmotic gradient as Na is
  absorbed through the lumenal wall
• Adult colons can handle 1.5 liters of fluid per
  day with only 100-150cc water excreted
• Under certain circumstances can handle 4.5
  liters/day without causing diarrhea

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Colon Physiology

• Rectal function
• Material passes into rectum via propulsive
  contractions until rectum begins to dilate
  causing reflex relaxation of the internal anal
  sphincter and contraction of the rectal detrussor
  muscles

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Rectal Function

• I want to go
• The puborectalis muscle (forms the anorectal
  angle) and levator ani muscles relax
  straightening the anorectal angle
• Straining increases intraabdominal pressure
• Feces is expelled

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Rectal Function

• Not now, my date wants to cuddle
• Contract external anal sphincter
• Prevents defecation and allows rectal wall to
  adapt to increased volume or reset for the next
  stimulation

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Pathophysiology of Constipation

• Defective/Impaired Propulsion (lt5)
• Diet deficient in bulk (fiber)
• Milk Protein Allergy
• Neuropathy/myopathy
• Cerebral palsy
• Spinal cord lesions
• Metabolic
• ? or ? Ca ?K ?Mag ?Phos
• Hypothyroidism, Hyperparathyroidism
• Cystic fibrosis
• Celiac disease
• Medications
• Narcotics
• Anticholinergics

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Pathophysiology of Constipation

• Defective/Impaired Sensation
• Primary sensory impairment such as spinal cord
  abnormalities (lt5)
• Secondary sensory abnormalities such as
  megarectum from chronic fecal retention
• Outlet Obstruction
• Mechanical (lt5)
• Anal stenosis
• Hirshsprungs Disease
• Functional
• gt95 of all constipation

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Differentiating Organic Disease (lt5)

• Failure to thrive
• Abdominal distension /- vomiting
• Anterior anus
• Tight anus
• Patulous anus
• Nevi or sinus in lumbosacral region
• Multiple Café-au-lait spots
• Abnormal tone or strength
• Abnormal lower extremity reflexes
• Blood in the stool

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Functional vs Organic
Functional Organic
Since birth Never Common
Retentive posturing Common Unusual
Encopresis Common Rare
Large caliber stools Common Unusual
Hx of obstruction Rare Common
Failure to Thrive Unusual Common
Distended abdomen Common Occasional
Stool in ampulla Common Rare
Rectal ampulla Dilated Narrow
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Common presentationsROME II Diagnostic Criteria

• Infant Dyschezia
• lt6mo
• Strains for 10 min
• Passage of soft stools
• Basic regulatory mechanisms to control defecation
  present in newborn
• Failure to coordinate increased intraabdominal
  pressure with relaxation of pelvic floor
• Dissipates with development

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Common presentationsROME II Diagnostic Criteria

• Functional constipation
• Infants and preschool children
• Associated with formula changes
• No organic cause
• Passing hard stools 2/week
• Use of fruit juices and medications with high
  sugar content softens stools and eases evacuation

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Common presentationsROME II Diagnostic Criteria

• Functional Fecal Retention
• Potty training and on
• Retentive behavior
• Defecation avoidance
• The Poop Dance
• Anxious
• Stiff body
• Cross legs walks on tip toes
• Hop up and down
• Runs to corner or hides behind couch
• Leads to fecal retention and overflow soiling

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Functional Constipation with Encopresis

• Dilation of rectum leads to loss of normal
  sensation to defecate, however, internal
  sphincter still relaxed
• Stool remains in contact with dehydrating
  physiology longer
• Proximal liquid stool runs around hard stool and
  passes out of anus often without awareness

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Triggers to functional constipation

• Most common is painful or frightening defecation
  single event can precipitate (i.e. like PTSD)
• Age differences
• Toddlers
• Dietary changes (Cows milk) lead to dry hard
  stools w/ fissures and pain
• Toilet training can lead to excessive parental
  pressure, anxiety, exertion of own will
• Older children
• Unpleasant toilet facilities away from home
• Sexual abuse
• All stool holding behaviors lead to further
  dehydration of stool and a vicious cycle of
  painful defecation and stooling avoidance

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Constipation in the ED

• Infant
• straining patterns
• Toddlers
• hard stools, blood on stool (fissures)
• Older children
• abdominal pain
• often unaware they are constipated

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Emergency Department Eval

• History
• Onset of sxs
• Growth pattern
• Presence of blood
• Consistency and caliber of stools
• Vomiting
• Recurrent abdominal pain
• PE
• Palpable mass in lower abd
• Observe anus location and local pathology
• Neurologic eval with anal wink, cremasteric
  reflex and DTRs in Les
• Digital Rectal Exam (Sensitivity
  88.6/Specificity 41.6)

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Emergency Department Eval

• Radiographs
• Several studies advocate use of plain abdominal
  films to assess presence of stool, however, stool
  in the colon is physiologically normal so what
  does it mean? Does presence of stool
  impaction?
• ED Physicians do rectal exams lt75 of the time
  and order radiographs 70 of the time.
• Frequently films used to explain sxs as
  attributed to constipation (i.e. appy explained
  away as constipation)
• conflicting evidence for an association between
  clinical symptoms of constipation and fecal
  loading of radiographs in children. Use of films
  cannot be supported. Reuchlin-Vroklage, et al
  Arch Pediatr Adolesc Med 2005 159

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Treatment

• Infants- Infant Dyschezia
• Mostly reassurance
• Osmotic agents to soften stools
• Prune juice/Malt soup extract/Corn syrup
• Glycerin suppositories for immediate evacuation
  (Avoid Use of Enemas in children under 2yo)
• Toddlers-Functional Constipation
• Avoid focus on toilet training
• Osmotic agents to soften stools and allow healing
  of fissures

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Treatment

• Older children- Functional Fecal Retention
• Two step procedure
• Immediate disimpaction (3-5 days)
• Oral or rectal routes
• Maintenance (6-12 months)
• Oral routes
• Typically mineral oil or polyethylene glycol

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Dosage Risks
Osmotic agents- Mag/Lactulose/Sorbitol Varies Cramps/flatulence/Mag intoxication
Lubricants- Mineral oil Disimpaction 15-30 cc/yr of life daily Maintenance 1-3cc/kg/d Lipoid pneumonitis/ Fat soluble Vit not malabsorbed
Stimulants- Senna/Bisacoyl Varies Idiosyncratic hepatitis/analgesic nephropathy/?K
Fiber- Bran/Psyllium 2.5cc powder in 240cc water TID Requires water if not enough can constipate
Osmotic enema- Phosphate enemas (Do not use in infants or neurologically impaired) 6cc/kg Trauma/bacterial translocation/electolyte shifts (?Phos/?Ca)
Lavage- PEG Disimpaction 25cc/kg/hr Maintenance 5-10cc/kg/d Or 0.78gm/kg/d Cramps/vomiting/ pneumonitis
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Enemas-A good and a bad idea

• Magnesium enemas (also PO)
• Acute mag toxicity??Ca/?Phos?Coma and Cardiac
  conduction defects, as well as, shock from fluid
  shifts
• Phosphate enemas
• Electrolyte disturbances and fluid shifts
• Soap suds enemas
• Bowel wall necrosis and perforation
• Tap water enemas
• Water intoxication/hypervolemia?electrolyte
  disturbance?seizures and death
• Milk Molasses enemas
• Fermentation?perforation
• Fluid and electrolyte shifts do happen

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A Medical Position Statement of the NASPGHAN

• General Rec
• Thorough Hx/PE-sufficient to dx functional
  constipation in most cases
• Stool for occult blood in all infants and
  children with risk factors for organic disease
• Abdominal radiographs can be useful
• Rectal Biopsy only reliable way to exclude
  Hirshsprungs Disease

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A Medical Position Statement of the NASPGHAN

• Rec for Infants
• Disimpaction via glycerin suppositories avoid
  enemas
• Osmotic and stimulant agents can be used
• Avoid mineral oil
• PEG has been shown to be safe in infants in a
  small limited trial

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A Medical Position Statement of the NASPGHAN

• Rec for children
• Disimpaction via oral or rectal routes okay
• Balanced diet with fiber containing foods
• Medications in conjunction with behavioral
  modification decreases time to remission
• PEG is effective for acute disimpaction and
  maintenance therapy and is the best tolerated of
  all regimens

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Hiddie Ho
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