A 7-year-old boy is brought in by his mother with faecal soiling for 6 months. He has a bowel motion every second day. Some days these are ‘giant’ stools, other days, small pellets. He soils his pants up to 5-6 times per week, usually in the daytime and is being bullied at school. He complains of daily abdominal pain. His mother has tried multiple short courses of laxatives and is convinced they don’t work. He has a palpable mass in his left iliac fossa that you are able to indent. What should you do next?
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Although you may groan a little inside, thinking ‘not another child with constipation’, just remember that up to one-third of these children will develop chronic constipation, leading to significant psychosocial consequences. Opportunities for early intervention are often ignored, yet an extra five minutes with these patients can make a great deal of difference to their long term outcome.[1]
What are the important history points?
- Frequency of stool
- Consistency – show the child a Bristol Chart
- Timing and onset of constipation
- Symptoms associated with defaecation i.e. distress on stooling, bleeding associated with hard stool, straining
- Overflow soiling
- Abdominal pain
- Precipitating factors i.e. fissures, change of diet, infections, medications
- Any neurological problems in legs?
- Diet and fluid intake – any changes in infant formula or weaning?
- Previous treatments tried
- Past medical history: passage of meconium (should be within 48 hrs after birth); previous episodes of constipation; previous anal fissure; growth and general wellbeing; family/social history.
What are the important examination points not to forget?
- Plot growth
- Abdominal examination
- Perianal exam – appearance, position, patency, fissures
- Spine – scoliosis
- Skin overlying the spine – discoloured/sinus/hairy patch/central pit
- Gluteal muscles – is there asymmetry?
- Gait
- Tone and strength in lower limbs
- (+ reflexes if there are features on exam that suggest neurological impairment)
- No PR! A PR exam should only be undertaken by a doctor competent to interpret features of anatomical abnormalities or Hirschsprung’s disease e.g. paediatric surgeons
What are the 'Red Flags'?
- Constipation from early infancy
- Delay in meconium >48hrs
- Ribbon stools
- Weakness in legs
- Abdo distension & vomiting
- Abnormal appearance of anus
- Asymmetry/flattening of gluteals
- Sacral agenesis
- Skin changes overlying spine
- Deformity of lower limbs – talipes
- Abnormal neuromuscular signs
- Abnormal reflexes
References
1. National Institute for Health and Clinical Excellence (2010). Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care. CG99. London: National Institute for Health and Clinical Excellence. Available from: https://www.nice.org.uk/guidance/CG99
