2004 06 09 clavell constipation

Information about 2004 06 09 clavell constipation

Published on October 31, 2007

Author: Dixon

Source: authorstream.com

Content

Pediatric Constipation:  Pediatric Constipation Maria I. Clavell, M.D. Department of Pediatrics Division of Gastroenterology Background:  Background 10% of children seeks medical attention because of constipation 2nd most referred condition to pediatric gastroenterologists Defecation patterns in health vary with age and is hard to define Fecal impaction with soiling is a common complication of chronic constipation Up to 5% of children suffer from soiling at time of entrance to school Rappaport LA, Levine MD. The prevention of constipation and encopresis: a developmental model and approach. Pediatr Clin North Am 1986; 33: 859-69. ETIOLOGY:  ETIOLOGY 95% 5% FUNCTIONAL ORGANIC ANATOMIC METABOLIC NEUROPATHIC ENDOCRINE CONNECTIVE TISSUE D/O DRUGS LEAD INTOXICATION OR BOTULISM Symptom based criteria for childhood defecation disorders - ROME II :  Symptom based criteria for childhood defecation disorders - ROME II Infant Dyschezia Functional Constipation Functional Fecal Retention ROME II: A multinational Consensus Document on Functional Gastrointestinal Disorders. Gut 1999; Suppl: II60-68. Infant Dyschezia:  Infant Dyschezia Under 6 months of age Otherwise healthy 10 minutes of straining/ crying Several times a day Successful passage of soft or liquid stools ROME II: A multinational Consensus Document on Functional Gastrointestinal Disorders. Gut 1999; Suppl: II60-68. Functional Constipation:  Functional Constipation Infants and Pre-school 2 weeks duration Pebble-like, hard stools Firm stools <2 times/week No evidence of structural, endocrine, or metabolic disease ROME II: A multinational Consensus Document on Functional Gastrointestinal Disorders. Gut 1999; Suppl: II60-68. Functional Fecal Retention:  Functional Fecal Retention Most common cause of chronic constipation Associated with fear and toilet refusal From infancy to 16 years old 12 weeks or longer Passage of large diameter stools < 2 times/week Retentive posturing ROME II: A multinational Consensus Document on Functional Gastrointestinal Disorders. Gut 1999; Suppl: II60-68. Physiology of Colon in defecation:  Physiology of Colon in defecation segmental, non-propagated phasic and tonic contractions -mixing and churning powerful high-amplitude propagated contractions- forward motion changes in colonic tone after a meal (gastro-colonic reflex) and upon awakening moving stools to the rectosigmoid region DIFFERENTIATING FEATURES OF FUNCTIONAL FECAL RETENTION (FFR) AND COLONIC NEUROMUSCULAR DISORDERS (CNMD) :  DIFFERENTIATING FEATURES OF FUNCTIONAL FECAL RETENTION (FFR) AND COLONIC NEUROMUSCULAR DISORDERS (CNMD) History FFR CNMD Starting at Birth Never Common Retentive Posturing Common Unusual Soiling/Encopresis Common Rare Large Caliber Stools Common Unusual History of Obstruction Rare Common Physical Exam Failure to thrive Unusual Common Distended abdomen Common Occasional Stool in Ampulla Common Rare Rectal Ampulla Dilated Narrow Physiology of defecation :  Physiology of defecation rectal wall is distended reflex contraction of the rectum with relaxation of the internal anal sphincter, pushing fecal material into the anal canal :“the firing position” sensitive lining of the anoderm perceives the stool decision to expel or to postpone defecation by contracting the external anal sphincter and the puborectalis muscle To go or not to go ?:  To go or not to go ? children who have had an unpleasant experience with a bowel movement last step of the defecation process becomes disrupted concrete way of thinking, react to unpleasant activities with vigorous, and often successful, attempts to avoid repeating those experiences at almost any cost Is this one going to hurt ? Stool Withholding Behavior:  Stool Withholding Behavior anxious body becomes stiff face turns pale begins to cross the legs hops up and down hides to a corner Consequences of Functional Fecal Retention:  Consequences of Functional Fecal Retention rectum becomes dilated and filled with large amounts of fecal material soiling occurs when liquid stool arrives in the rectum, encounters impacted stool, and begins to seep around it liquid stool is passed into the undergarment of the child without his/her awareness Impaction:  Impaction hard mass in the lower abdomen on physical exam a dilated rectum filled with a large amount of stool on rectal exam excessive stool in the colon on radiography North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition:  North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Determine if fecal impaction is present Treat impaction if present prior to maintenance therapy When oral medication is used, it should be a softener not a stimulant Parental education Close follow up with behavior modification Baker SS et al. Constipation in Infants and Children: Evaluation and Treatment. J Pediatr Gastroenterol Nutr 1999; 612-626. Goal of therapy:  Goal of therapy Evacuation of stools without pain Management strategy for treatment of chronic constipation :  Management strategy for treatment of chronic constipation DISIMPACTION maintenance therapy monitoring and behavior modification Disimpaction:  Disimpaction Prior to the initiation of maintenance therapy Oral, rectal route or combination Oral route is non-invasive and gives the child sense of power Rectal route is faster but invasive No randomized studies comparing the effect of one to the other Disimpaction using oral medication:  Disimpaction using oral medication Mineral oil and polyethylene glycol solution have been shown to be effective No controlled studies in magnesium citrate, lactulose, senna, and bisacodyl but reported to be effective Problems include large volumes and bad taste leading to poor compliance Commonly Used Medications:  Commonly Used Medications AGENTS DOSAGES SIDE EFFECTS OSMOTIC: Lactulose/ 1-3 ml/kg/day ÷ BID bloating, cramps, diarrhea Sorbitol Magnesium citrate 1-3 ml/kg/day (< 6y) hypermagnesemia, 100-150 ml/day (6-12y) hypophosphatemia and 150-300 m/ day (> 12y) secondary hypocalcemia Magnesium hydroxide 1-3 ml/kg of 400mg/5 ml hypermagnesemia available as liquid hypophosphatemia and secondary hypocalcemia LUBRICANT: Mineral Oil 1-3 ml/kg/day (maintenance) aspiration risk 15-30 ml/year of age (disimpaction) LAVAGE: Polyethylene Glycol (PEG) 5-10 ml/kg/day nausea, vomiting, cramps, risk for aspiration 25 ml/kg/hr via nasogastric tube STIMULANTS: Senna 2.5 –7.5 ml/day (2-6y) melanosis coli, hepatitis 5-15 ml/day (6-12y) In conclusion…:  In conclusion… Childhood constipation is common Painful defecation and fear are contributing factors Fecal impaction and subsequent soiling are usually associated Disimpaction prior to starting maintenance medication is highly recommended

Related presentations


Other presentations created by Dixon

Types of Flower Shop
06. 11. 2007
0 views

Types of Flower Shop

ALCATELe salud
30. 11. 2007
0 views

ALCATELe salud

Upanishads
06. 12. 2007
0 views

Upanishads

Teaching World History
25. 10. 2007
0 views

Teaching World History

400 Silent Years
30. 10. 2007
0 views

400 Silent Years

invasion2
31. 10. 2007
0 views

invasion2

PresentazioneSofia20 05
01. 11. 2007
0 views

PresentazioneSofia20 05

Ch09
02. 11. 2007
0 views

Ch09

EEA Workshop Buhaug IMO index
06. 11. 2007
0 views

EEA Workshop Buhaug IMO index

reynolds
07. 11. 2007
0 views

reynolds

Week5
15. 11. 2007
0 views

Week5

The best of two worlds
16. 11. 2007
0 views

The best of two worlds

iso e
23. 11. 2007
0 views

iso e

pollination
17. 12. 2007
0 views

pollination

savannas
26. 11. 2007
0 views

savannas

discourse
12. 12. 2007
0 views

discourse

S4 03Dwaine Clarke
25. 12. 2007
0 views

S4 03Dwaine Clarke

Field Forage
28. 12. 2007
0 views

Field Forage

Ethics Principles May 2003 1
29. 12. 2007
0 views

Ethics Principles May 2003 1

Alan Turing is Da Bombe
02. 01. 2008
0 views

Alan Turing is Da Bombe

Chalut1
03. 01. 2008
0 views

Chalut1

Search and Rescue
03. 01. 2008
0 views

Search and Rescue

StigmaLeipzigAtt
04. 01. 2008
0 views

StigmaLeipzigAtt

saworkshop pp addressing uebel
07. 01. 2008
0 views

saworkshop pp addressing uebel

file 10684
07. 01. 2008
0 views

file 10684

Laborin Mario
15. 11. 2007
0 views

Laborin Mario

una madre unica 21186
01. 10. 2007
0 views

una madre unica 21186

PDSI
21. 11. 2007
0 views

PDSI

BerwickPPT1sp04
10. 12. 2007
0 views

BerwickPPT1sp04

FDIprezentace 2
14. 11. 2007
0 views

FDIprezentace 2

bisc Progress Review 17 june
03. 12. 2007
0 views

bisc Progress Review 17 june

Lecture12Handout
30. 12. 2007
0 views

Lecture12Handout

Beauty05 biglietti
30. 10. 2007
0 views

Beauty05 biglietti

ch14
20. 02. 2008
0 views

ch14

A4081
24. 02. 2008
0 views

A4081

ELECTRONICversion
27. 02. 2008
0 views

ELECTRONICversion

italie powerpoint 04 05
31. 10. 2007
0 views

italie powerpoint 04 05

lecture 11 travel writing
27. 03. 2008
0 views

lecture 11 travel writing

BP ICIW07
31. 10. 2007
0 views

BP ICIW07

GOLINI
29. 10. 2007
0 views

GOLINI

WAYS OF DIVIDING THE WORLD
24. 12. 2007
0 views

WAYS OF DIVIDING THE WORLD

twp
23. 12. 2007
0 views

twp

barrett
02. 01. 2008
0 views

barrett

SLAC 02022005 AMvdB
05. 12. 2007
0 views

SLAC 02022005 AMvdB

Navas 30
23. 11. 2007
0 views

Navas 30

InSeT
16. 11. 2007
0 views

InSeT

Intermediate Microsoft Word
12. 03. 2008
0 views

Intermediate Microsoft Word

shin
11. 12. 2007
0 views

shin

SESAMI Menichelli
29. 10. 2007
0 views

SESAMI Menichelli

Wireless Workshop Tyndall
28. 11. 2007
0 views

Wireless Workshop Tyndall