Atan Baas Sinuhaji

CONSTIPATION

Sub Division of Pediatrics Gastroentero-HepatolgyDepartment of ChildHealth,School of Medicine

University of Sumatera Utara

MEDAN

DEFECATIONDEFECATION

REGULAR PATTERN CONSTIPATIONREGULAR PATTERN CONSTIPATION

GOOD HEALTH BACKUP OF STOOLSGOOD HEALTH BACKUP OF STOOLS

ACCUMULATION OF ACCUMULATION OF TOXIN IN THE BLOODTOXIN IN THE BLOOD

DEFINITION OF CONSTIPATIONDEFINITION OF CONSTIPATION

VARIES AMONG INDIVIDUALVARIES AMONG INDIVIDUAL

HARD LARGE INFREQUENT PAIN OR HARD LARGE INFREQUENT PAIN OR STOOLSSTOOLS STOOLSSTOOLS STOOLSSTOOLS PRESSUREPRESSURE

WHILE WHILE STOOLINGSTOOLING

CONSTIPATIONCONSTIPATIONCONSTIPATIONCONSTIPATION

FREQ. DEFECATION ↓↓↓↓↓↓↓↓

- HARD, DRY STOOLS- DIFFICULT / PAIN- INCONTINENCE

= SOILING= ENCOPRESIS

FREQUENCY OF DEFECATION

NORMAL = 2 X / DAY- 1 X/2DAYS

ABNORMAL < 1 X / 2 DAYS

SOILINGSOILINGSOILINGSOILING

WITHOUT CONSTIPATION WITH CONSTIPATIONWITHOUT CONSTIPATION WITH CONSTIPATION

MENTAL RETARDATION

CLASSIFICATIONCLASSIFICATIONCLASSIFICATIONCLASSIFICATION

1. ACUTE / CHRONIC ( ≥≥≥≥ 3 MONTHS )

2. SEVERITY

3. ORGANIC / IDIOPATHIC3. ORGANIC / IDIOPATHIC

4. PATHOGENESIS

5. ANORECTAL DYSFUNCTION (+)/(-)

6.OBSTRUCTIVE / FUNCTIONAL

7. CONGENITAL / ACQUIRED

ORGANIC

1.SYSTEMIC

@ DRUGS@ ENDOCRINE AND METABOLIC DISORDERS@ OTHERS ( faulty diet or bowel habit, long distance travel )

2.NEUROGENIC

3.OBSTRUCTIVE LESION

4.FUNCTIONAL CONSTIPATION

@ ABNORMALITIES OF MUSCLE FUNCTION (eg.COLONIC INERTIA)@ ANORECTAL OR PELVIC FLOOR DISORDERS@ PSYCHOLOGICAL DISEASES

Rome III

Functional constipation

At least once per week for at least 2 months before diagnosis .

Must included ≥ 2 of following criteria.

1. ≤ 3 defecations / wk

2. ≥≥≥≥ 1 episode of fecal incontinence/wk2. ≥≥≥≥ 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

DEFECATION

RECTAL FILLING

DEFECATION

PROPULSION OF RECTAL CONTENTS

- CONTRACTION

- RECTAL PRESSURE

- DISTENTION

PROPULSION OF RECTAL CONTENTS

- RECTAL PRESSURE

- URGE TO DEFECATE

- RELAXING THE ANAL SPHINCTER

- STRAINING

ANAL SPHINCTER

INTERNAL EXTERNAL

INVOLUNTARY VOLUNTARY

STRAINING

@ INCREASING INTRA ABDOMINAL PRESSURE

@ INHIBITION IN MUSCLE ACTIVITY OF THE PELVIC FLOOR

@ ANORECTAL ANGLE INCREASE 800 TO 140O DUE TO RELAXATION

OF THE PUBORECTAL MUSCLE

NORMAL DEFECATION INVOLVES SYNCHRONIZEDINVOLUNTARY AND VOLUNTARY FUNCTIONS

CONSTIPATIONCONSTIPATIONCONSTIPATIONCONSTIPATION

IMPAIRED RECTAL IMPAIRED RECTAL IMPAIRED RECTAL

FILLING

IMPAIRED RECTAL

PROPULSION

IMPAIRED RECTAL FILLINGIMPAIRED RECTAL FILLINGIMPAIRED RECTAL FILLINGIMPAIRED RECTAL FILLING

IMPAIRED PERISTALSIS OBSTRUCTION

DRUGS HORMONAL

MORBUS HIRSCHSPRUNG -SPASMOLYTIC

-CODEINHYPOTHYROIDISM

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

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

WITHHOLD STOOLSWITHHOLD STOOLS

=PAIN=PAIN�� FISSUREFISSURE

=LACK OF TIME=LACK OF TIME

=POOR HYGIEN=POOR HYGIEN=POOR HYGIEN=POOR HYGIEN

=NET ALLOWED=NET ALLOWED�� SCHOOLSCHOOL

CONSEQUENCESCONSEQUENCESCONSEQUENCESCONSEQUENCES

1. VOMITING

2. ABDOMINAL PAIN

3. ABDOMINAL DISTENTION

4. PAIN TO DEFECATE4. PAIN TO DEFECATE

5. RECTAL BLEEDING �ANAL FISSURE

6. ANOREXIA

7. ABDOMINAL MASS � RETENTION OF URINE

8. CHRONIC - PCM

- MEGACOLON

MEGACOLONMEGACOLONMEGACOLONMEGACOLON

CONGENITAL AGANGLIONIC

= M. HIRSCHSPRUNGIDIOPATHIC

= ACQUIRED = CHRONIC IDIOPATHIC CONSTIPATION

MEGACOLONSTOOLS MEGACOLON

PARADOXAL DIARRHOEA

Ganglion (-)PeristalsisObstruction

External Anal Sphincter

INCONTINENTIAALVI

BARIUMIN LOOP

MEGACOLON

IDIOPATHIC= ACQUIRED CONGENITAL

1. ONSET 2-3 YEARS 1ST DAY

2. SOILING (+) (-)

3. PARADOXAL (-) (+)

DIARRHOEADIARRHOEA

4. PCM (-) (+)

5. ABD. DISTENTION (+) (++)

6. ANAL SPHINCTER LOOSE TIGHT

7. RECTAL AMPULLA FULL EMPTY

8. ENTEROCOLITIS (-) (+)

9. TREATMENT MEDICAL SURGERY

M. HIRSCHSPRUNG

DIAGNOSIS

IRRIGATION

FULMINANT

ENTEROCOLITIS

OPERATION

COLOSTOMY

DEFINITIVE (6-12 MONTHS)DEATH

CHRONIC IDIOPHATIC CHRONIC IDIOPHATIC CONSTIPATIONCONSTIPATION

1.1. EVACUATION OF FIRM STOOLS EVACUATION OF FIRM STOOLS (FECAL DISIMPACTION) (FECAL DISIMPACTION)

�� MgSOMgSO44

�� IRRIGATIONIRRIGATION

�� etcetc

2.2. MAINTENANCE MAINTENANCE

1.1. DIETARY MANIPULATION DIETARY MANIPULATION →→→→→→→→FIBERS FIBERS >>> >>> 1.1. DIETARY MANIPULATION DIETARY MANIPULATION →→→→→→→→FIBERS FIBERS >>> >>>

TAP WATER TAP WATER >>>>>>

2.2. TOILET TRAININGTOILET TRAINING

3.3. DRUGS :DRUGS :a. SPASMOLYTIC (-)b. LAXANTIA :

• lactulose

• polyethylene glycol

c. ANAEROB BACTERIAL:

• metronidazole

Behaviour therapytoilet 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

OLD PARADIGM OLD PARADIGM

CHRONIC CONSTIPATION IS A BEHAVIOUR/LEARNING DISORDERCHRONIC CONSTIPATION IS A BEHAVIOUR/LEARNING DISORDER

COMMON CAUSESCOMMON CAUSESBehaviour / LearningBehaviour / Learning

= Adverse life = Adverse life eventevent= Defiant behaviour= Defiant behaviour

== Intellectual disabilityIntellectual disability

( plus rare organic causes )( plus rare organic causes )

= Cystic fibrosis= Cystic fibrosis

= Hirschsprung’s Disease= Hirschsprung’s Disease

NEW PARADIGM NEW PARADIGM

CHRONIC CONSTIPATION IS AN ORGANIC OR A BEHAVIOUR/LEARNING CHRONIC CONSTIPATION IS AN ORGANIC OR A BEHAVIOUR/LEARNING DISORDERDISORDER

COMMON CAUSESCOMMON CAUSES

Behaviour / Learning OrganicBehaviour / Learning Organic

= Adverse life event = Colonic dysmotily= Adverse life event = Colonic dysmotily

= Defiant behaviour = Outlet obstruction= Defiant behaviour = Outlet obstruction

== Intellectual disabilityIntellectual disability

( plus rare organic causes )( plus rare organic causes )

= Cystic fibrosis= Cystic fibrosis

= Hirschsprung’s Disease= Hirschsprung’s Disease

IN 70 %AFFECTED CHILDREN,CONSTIPATION IN 70 %AFFECTED CHILDREN,CONSTIPATION RESPONS WITHIN 2 YEARS OF DIAGNOSIS TO RESPONS WITHIN 2 YEARS OF DIAGNOSIS TO

MEDICAL THERAPIES OR BEHAVIORAL MEDICAL THERAPIES OR BEHAVIORAL MODIFICATIONMODIFICATION

THE REMAINING CHILDREN ARE THE REMAINING CHILDREN ARE CLASSIFIED WITH CHRONIC CLASSIFIED WITH CHRONIC TREATMENTTREATMENT-- RESISTANT CONSTIPATIONRESISTANT CONSTIPATION

CHRONIC TREATMENTCHRONIC TREATMENT--RESISTANT RESISTANT CONSTIPATIONCONSTIPATION

IDIOPATHIC ORGANICIDIOPATHIC ORGANIC

FUNCTIONALFUNCTIONAL

FUNCTIONAL

COLONIC TRANSIT TIME

NORMAL ABNORMAL

HOLD UP AT ANO-RECTUM

FUNCTIONAL FECAL REENTION SLOW TRANSIT CONSTIPATION

SLOW TRANSIT CONSTIPATIONSLOW TRANSIT CONSTIPATION

DELAY IN COLONIC TRANSIT TIMEDELAY IN COLONIC TRANSIT TIME

INTRACTABLE CONSTIPATIONINTRACTABLE CONSTIPATION

NOT RESPONSE TONOT RESPONSE TO

LAXATIVE DIET CHANGE IN LIFE STYLE LAXATIVE DIET CHANGE IN LIFE STYLE

CONCLUSIONSCONCLUSIONS

�� CONSTIPATIONCONSTIPATION��COMMON PROBLEM COMMON PROBLEM

DURING CHILDHOODDURING CHILDHOOD

�� ACUTE FORMACUTE FORM��EASILY CORRECTEDEASILY CORRECTED

�� ACUTE FORMACUTE FORM��NOT PROPERLY NOT PROPERLY �� ACUTE FORMACUTE FORM��NOT PROPERLY NOT PROPERLY TREATEDTREATED��CYCLE UNEXPELLED FECES CYCLE UNEXPELLED FECES BEGINSBEGINS��COMPLICATIONCOMPLICATION

�� CHRONIC CONSTIPATION IS AN ORGANIC CHRONIC CONSTIPATION IS AN ORGANIC CAUSES NOT ONLY BEHAVIOUR/LEARNING CAUSES NOT ONLY BEHAVIOUR/LEARNING DISORDERDISORDER

SLOW TRANSIT CONSTIPATIONSLOW TRANSIT CONSTIPATION

DELAY IN COLONIC TRANSIT TIMEDELAY IN COLONIC TRANSIT TIME

INTRACTABLE CONSTIPATIONINTRACTABLE CONSTIPATIONTERIMA KASIHNOT RESPONSE TONOT RESPONSE TO

LAXATIVE DIET CHANGE IN LIFE LAXATIVE DIET CHANGE IN LIFE

STYLESTYLE