Constipation

• What is the criteria for constipation?

  Rome IV criteria

  • Fewer than three bowel movements per week
  • Hard stool in more than 25% of bowel movements
  • Tenesmus (sense of incomplete evacuation) in more than 25% of bowel movements
  • Excessive straining in more than 25% of bowel movements
  • A need for manual evacuation of bowel movements
• How can constipation be categorised?


  Primary constipation

  • no organic cause
  • thought to be due to dysregulation of function of the colon or anorectal muscles

  Secondary constipation

  • due to other factors (diet, medications, metabolic, endocrine or neurological disorders or obstruction)
• What are the lifestyle RFs for constipation?

  Habitually not opening the bowels

  Low fibre diet

  Poor fluid intake & dehydration

  Sedentary lifestyle

  Psychosocial problems (difficult home/school environment -> keep safeguarding in mind)
• What are the possible secondary causes of constipation?

  Hirschsprung's disease

  Cystic fibrosis

  Hypothyroidism

  Spinal cord lesions

  Sexual abuse

  Intestinal obstruction

  Anal stenosis

  Cows milk intolerance
• How can constipation cause desensitisation of the rectum?


  Often develop habit of not opening bowels when need to -> overtime lose sensation of needing to open bowels -> start to retain faeces in rectum -> faecal impaction (large, hard stool blocks rectum) -> overtime rectum stretches as it fills with more faeces -> further desensitisation -> becomes more difficult to treat constipation
• What are the red flags of constipation that should think about serious underlying conditions?


  Not passing meconium within 48 hrs of birth -> CF, Hirschsprung's disease

  Neurological signs & symptoms -> SP, spinal cord lesion

  Vomiting -> intestinal obstruction, Hirschsprung's disease

  Ribbon stool -> anal stenosis

  Abnormal anus -> anal stenosis, IBD, sexual abuse

  Abnormal lower back or buttocks -> spina bifida, spinal cord lesion, sacral agenesis

  Failure to thrive -> coeliac disease, hypothyroidism, safeguarding

  Acute severe abdominal pain & bloating -> obstruction, intersussception
• What are the complications of constipation?


  Pain

  Reduced sensation

  Anal fissures

  Haemorrhoids

  Overflow & soiling

  Psychosocial morbidity
• What is encopresis?


  Faecal incontinence
• When is encopresis considered pathological?


  Past 4 yrs old
• What is encopresis usually a sign of?


  Chronic constipation

  Rectum becomes stretched & loses sensation

  Large stools remain in rectum, but loose stools are able to bypass blockage & leak out -> soiling
• Apart from chronic constipation, what else can encopresis be caused by?


  Spina bifida

  Hirschsprung's disease

  CP

  Learning disability

  Psychosocial stress

  Abuse