Constipation (Case 7)

Chapter 35 Constipation (Case 7)



Gerald M. Fendrick, MD




Case


A 6-year-old boy with infrequent bowel movements, every 6 to 7 days. Stools are large, hard, and painful to pass and have clogged the toilet. There are frequent soiling and malodor. Embarrassment in school prompted this visit. Abdominal examination was positive for what appeared to be large amounts of stool in the lower left abdomen.




Differential Diagnosis









Functional constipation Hirschsprung disease Hypothyroidism


Speaking Intelligently


When I evaluate a patient with constipation, the term has to be defined. Is the definition based on frequency of stools or quality of the stool? Once it is established that constipation is really present, I ask myself if the history and physical examination lean toward a diagnosis of functional or organic constipation. There is a long differential diagnosis for constipation; however, functional constipation, which is the etiology in 95% of cases, must be considered first. Questions should be asked about the time of the first bowel movement after birth (which most parents will not know or recall), toilet training history, bowel history, treatment attempted for the problem, and medications and dietary habits. Constipation may also be accompanied by complaints of abdominal pain, decreased appetite, irritability, and occasionally vomiting.



Patient Care



Clinical Thinking



• Is there fecal impaction?

• Does the history or physical examination suggest an organic etiology?

• What are the course and duration of constipation?


History



• Is time of first meconium passage known?

• Did constipation begin around toilet training?

• Did constipation begin with attendance at preschool or grade school?

• Have there been any dietary changes?

• A recent viral syndrome may cause transient ileus.

• Is the child on medications (including over-the-counter preparations), such as calcium, iron, antihistamines, anticholinergics, diuretics, or opiates?

• Are symptoms present to suggest an endocrine, metabolic, or neuromuscular problem?

• Are there any associated gastrointestinal (GI) abnormalities, such as failure to thrive or gastroesophageal reflux disease (GERD)?

• Functional constipation can be accurately diagnosed with history and physical examination, and additional testing is usually not indicated.


Physical Examination



• Note general well-being and overall nutritional status, looking for signs of systemic disease.

• Review height, weight, body mass index (BMI), and prior growth pattern.

• Palpate the neck for thyromegaly.

• Perform an abdominal examination with particular attention to overall contour, bowel sounds, and palpation and percussion for presence of masses or stool. Note quality of abdominal musculature.

• Inspect the perianal, perineal, and lumbosacral areas for fissures, anatomic abnormalities (anteriorly placed anus), dimples, tufts of hair, masses, or hemangiomas.

• In functional constipation, digital anorectal examination will be positive for a large rectal vault filled with hard stool, whereas in Hirschsprung disease the sphincter tone is tight with an empty narrow vault.


Tests for Consideration



• Rectal suction biopsy: For Hirschsprung disease $606

• Anorectal manometry: To evaluate for Hirschsprung disease $555

• Urinalysis: If impaction present $95

• Urine culture: If impaction present $148

• Complete blood count (CBC): If failure to thrive $116

• Celiac panel: If failure to thrive $225

• Thyroid-stimulating hormone (TSH), triiodothyronine (T3), and free thyroxine (T4): If concern for hypothyroidism $194

• Electrolytes, including calcium and magnesium: If decreased fluid intake or metabolic abnormalities suspected $290


Imaging Considerations



→ Single view abdominal radiograph: Can demonstrate degree of fecal retention, rectal and colonic dilation $170
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Constipation (Case 7)

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