1

A 10-year-old male patient presents to your urgent care center with 2 days of generalized abdominal pain, associated with nonbilious vomiting and decreased appetite. His abdominal exam is benign. He describes straining with bowel movements and hard stool. Is constipation a common disorder in children?

Constipation is one of the most common chronic disorders of childhood. It is responsible for 3% of all primary care visits for children and up to 25% of pediatric gastroenterology visits.

2

What is considered constipation in children?

Constipation can be broadly defined as infrequent bowel movements with at least one of the following: painful defecation, hard stools, purposeful fecal retention, fecal soiling, encopresis. Outside the neonatal period, childhood constipation is common and almost always functional without an organic etiology.

3

What are the symptoms of constipation?

A child typically presents with a chief complaint of hard pelletlike stools, difficulty or pain with defecating, abdominal pain, abdominal distension, vomiting, or anorexia.

4

What symptoms are red flags for an underlying organic cause of constipation?

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  Delayed passage of meconium

  
  
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  Significant abdominal distension

  
  
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  Abnormal development

  
  
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  Constipation since birth

  
  
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  Bloody stools (absence of anal fissure)

  
  
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  Weight loss and/or failure to thrive

5

What causes functional constipation in children?

Functional constipation is commonly caused by painful bowel movements prompting the child to withhold stool. To avoid a painful bowel movement, the child will contract the anal sphincter and/or gluteal muscles, leading to stool retention, prolonged fecal stasis with reabsorption of fluid, and then a harder, larger stool that is more painful to pass. This cycle may occur with toilet training, changes in routine or diet, stressful events, illness, lack of accessible toilets (e.g., at school), or a busy child who defers defecation.

6

How do you diagnose constipation?

A history and physical examination are usually sufficient to distinguish functional constipation from constipation with an organic etiology. A history should review the frequency, consistency, and size of stools; age of onset of symptoms; meconium passage after birth; recent stressors; prior history and therapies; presence of withholding behaviors, pain, or bleeding with bowel movements; abdominal pain; and fecal incontinence. Physical exam should include an abdominal exam; external examination of the perineum, perianal areas, thyroid, and spine; and a neurologic evaluation for appropriate reflexes (cremasteric, anal wink, and patellar).

7

What diagnosis must be considered in a neonate or infant presenting with constipation, poor feeding, and a weak cry?

Infant botulism needs to be considered. Infant botulism is characterized by constipation followed by neuromuscular paralysis or “floppiness.” Symptoms include constipation, history of poor feeding, difficulty latching and suckling, lethargy, and a weak cry. Exposure to honey or a construction site may be the cause.

8

In a child presenting with constipation since birth, what disorder must be considered?

Infants and children often with history of constipation since birth or delayed meconium passing (>48 hr) may have Hirschsprung disease. Children diagnosed later in childhood may have a history of poor growth, severe recalcitrant constipation, and intermittent vomiting. Physical exam may present with signs of enterocolitis, abdominal distension and pain, poor feeding, and foul-smelling watery stools.

9

Is a digital examination of the anorectum useful in diagnosing constipation?

A digital examination is recommended to assess for perianal sensation, anal tone, rectum size, anal wink, rectal stool load, and consistency. Children with normal neonatal courses or clear withholding behaviors may have the rectal examination deferred. The presence of a hard mass in the lower abdomen and/or a dilated rectum with hard stool indicates fecal impaction.

10

Is abdominal radiography a valuable diagnostic tool for diagnosing constipation?

Abdominal radiography is not recommended for diagnosing constipation due to lack of interobserver reliability and accuracy, but it may be useful to determine the extent of fecal impaction. It can be used for specific clinical circumstances in which a rectal examination is unreasonable (child with history of trauma) or the diagnosis is uncertain.

11

How is constipation treated?

When fecal impaction is present, oral or rectal disimpaction is required before the initiation of maintenance therapy to keep the rectum empty and allow the rectum to return to its normal size. Maintenance therapy may be needed for several months. Parental education, behavior modification, and close follow-up are essential to prevent reoccurrence. If an organic cause is found, treatment involves addressing the underlying organic problem.

12

What are the effective therapies for fecal impaction in children?

A number of therapies are available with the advent of polyethylene glycol-based solutions being first line, due to the medication’s effectiveness, ease to administer, noninvasiveness, and ability to tolerate. Rectal therapies and polyethylene glycol are similarly effective in the treatment of fecal impaction in children. Oral therapies include osmotics (polyethylene glycol, magnesium citrate), stimulants (senna bisacodyl), and lubricants (mineral oil). Rectal agents include enemas (mineral oil, phosphate, normal saline) and suppositories (bisacodyl, glycerin).

13

What is the goal of constipation maintenance therapy?

The goal is to avoid reaccumulation of stool by maintaining soft bowel movements. Studies show addition of laxatives is necessary and more effective than behavior modification alone. Recent studies show addition of enemas to oral laxative regimens does not improve outcomes in children with severe constipation. Polyethylene glycol achieves equal or better treatment success than other laxatives such as lactulose or milk of magnesia. Maintenance medications need to be continued for several weeks to months.

14

What are the possible complications of constipation?

Chronic abdominal pain, bowel obstruction, rectal fissures, enuresis, encopresis, urinary retention, urinary tract infection, rectal prolapse, and social stigmata are all possible complications.

15

What is the most common pediatric surgical emergency?

Appendicitis, with approximately 70,000 pediatric cases per year. Appendicitis is the most common surgical condition in children who present with abdominal pain. Lymphoid or fecalith obstructs the appendiceal lumen, and the appendix becomes distended with ischemia and necrosis developing.

16

What is the misdiagnosis rate in children less than 2 years?

Nearly 100%, due to the difficulty in localizing abdominal pain in nonverbal children. Many cases present similar to other common pediatric diagnoses such as constipation and gastroenteritis. As the age of the child progresses, the misdiagnosis rates improve.

17

What is the classic clinical examination you find in appendicitis?

Less than 50% of pediatric patients will present with the classic presentation. Patients with appendicitis classically present with visceral, vague, poorly localized, periumbilical pain. Within 6 to 48 hours, the pain becomes parietal as the overlying peritoneum becomes inflamed; the pain then becomes well localized and constant in the right iliac fossa.

18

What is the Rovsing sign?

Pushing on the abdomen in the left lower quadrant elicits pain in the right lower quadrant.

19

What is the psoas sign?

Pain on passive extension of the right thigh with the patient lying on the left side.

20

What is the obturator sign?

Pain on passive internal rotation of the flexed right thigh.

21

What laboratories should be sent for suspected appendicitis?

White blood cell (WBC) count, C-reactive protein (CRP), and urinalysis, and urine pregnancy; also consider serum chemistry. Combining use of WBC and CRP increases sensitivity of laboratory evaluation for possible appendicitis.

22

What is the radiographic diagnostic study of choice for diagnosing pediatric appendicitis?

Ultrasound is now the diagnostic modality of choice in pediatrics. With abdominal computed tomography (CT) scan, there are significantly more radiation risks for children and possible long-term sequelae. Watchful waiting and serial abdominal examinations now have a significant role in diagnosing pediatric appendicitis. CT scans provide better diagnostic information for perforated appendicitis or suspected intraabdominal abscesses. Several emergency departments in the United States are using MRI scans as the first-line diagnostic test to rule out appendicitis and ovarian pathology.

23

In a male patient presenting with localized abdominal pain, why should the genital area always be examined?

The male scrotum and testes should always be examined to rule out testicular torsion/pathology and inguinal hernias. Referred abdominal pain may occur due to the stomach and small intestine having shared innervation with the testicle and epididymis.