Curso Actualizaciones en Pediatra

Constipacin Crnica en Pediatra

Dr. Mario Carrasco Salgado Docente U. de Concepcin Pediatra Gastroenterlogo Infantil Hospital Las Higueras Talcahuano

Constipacin Crnica en Pediatra

Introduccin: La constipacin con o sin encopresis es un problema muy frecuente en el nio. Representa entre el 3 5% de las consultas peditricas y el 25% de las interconsultas a los gastroenterlogos infantiles. Es uno de los 10 motivos ms frecuentes de las consultas a pediatras generales.

Constipacin Crnica en Pediatra

Tabla 1: Normal frecuency of bowel movements
Age Bowel movements per week Bowel movements per day

0-3 Months Breast fed Frmula fed 6-12 Months 1-3 Years

5 40 5 - 28
5 - 28 4 - 21

2,9 2,0
1,8 1,4

More than 3 years

3 - 14

1,0
Adapted from Fontana M. Bianch C. Acta Paediatr Scand 1987

Constipacin Crnica en Pediatra

Definicin: El estreimiento se define de manera simple, como un trastorno en la frecuencia de la defecacin o, en el tamao o consistencia de las heces. No obstante esta definicin es muy imprecisa. Los criterios de Iowa han sido ampliamente utilizados. Ms reciente: un grupo de expertos propuso los denominados Criterios de Roma II

Constipacin Crnica en Pediatra

Consenso de Paris: Considera que existe estreimiento crnico cuando concurren 2 o ms de las siguientes caractersticas durante ms de 8 semanas. Menos de 3 deposiciones por semana. Ms de un episodio de incontinencia fecal por semana. Heces abundantes en recto o masa abdominal palpable. Deposiciones tan grandes que pueden obstruir el inodoro. Conducta y postura retentivas. Defecacin dolorosa.

Constipacin Crnica en Pediatra

Terminologa sugerida por el consenso de Paris. Incontinencia fecal: Deposiciones en un lugar inapropiado. Incontinencia fecal orgnica: Resultado de una enfermedad orgnica. Incontinencia fecal funcional: 2 tipos Asociada a estreimiento No asociada a estreimiento (no retentiva). Impactacin fecal: Heces abundantes en recto, que no pueden eliminarse. Disergia de suelo plvico: Incapacidad para el suelo plvico durante la defecacin.

Fisiopatologa de la constipacin y encopresis

Organizacin de la musculatura e inervacin intrnseca del tubo digestivo. (Tomado de Navarro I. 1995)

Plexo Mioentrico

Capa Muscular ext.

Plexo Submucoso

Capa Muscular int.

Mucosa Lumen

Organizacin de la motilidad colnica

S.N. Intrnseco: Plexos mioentricos y submucoso con

efecto inhibidor permanente sobre musculatura lisa. S.N.C.: Vas simpticas y parasimpticas modula y controla los plexos intrnsecos. Neuromediadores: Acetilcolina, noradrenalina y una serie de molculas secretadas: encefalinas, sustancia P, VIP, etc.

Motilidad Colnica
El colon es recorrido por 2 tipos de ondas de contraccin: las contracciones lentas (retro y autopropulsivas) y las contracciones de masa. Los movimientos anterogrados: Colon derecho Los movimientos anterogrados y retrgrados en Colon izquierdo Contracciones de masa: varias veces al da (al despertarse y despus de las comidas) Papel del colon es triple: mantiene la flora bacteriana, reabsorbe el agua y regula el trnsito y almacenamiento (transitorio).

Fisiologa de la defecacin normal

Distensin Rectal

Percepcin conciente

Relajacin EAI

Contraccin EAE y M. Puborectal

Relajacin Puborectal

Mantenimiento

Aumento de presin Intraabdominal

Desaparicin de la urgencia

Relajacin EAE

Expulsin del bolo y Vaciamiento rectal

Estreimiento
Cada elemento considerado anteriormente puede ser causa de estreimiento: Aumento de reabsorcin de agua Alteracin de la propulsin Almacenamiento inapropiado Aumento de la actividad segmentaria Anomalas en la relajacin del EAE y de la musculatura puborectal (dolor)

Etiologa de la Constipacin
El estreimiento crnico es idioptico en el 90 95%

de los casos, no orgnica, multifactorial La prevalencia es mayor en nios de muy bajo peso y en los afectados por P.C. Afecta por igual a ambos sexos. La incontinencia fecal es ms frecuente en varones. Con frecuencia hay antecedentes familiares.

Causas del Estreimiento con o sin Encopresis

Tabla II A. Idioptica 90-95% B. Orgnica o Secundaria
1) Lesiones Anales Fisura anal Ano anterior Estenosis y atresia anal 2) Estreimiento Neurognico (inervacin) a) Trastorno de la mdula espinal
Parlisis cerebral hipotonia b) Enfermedad de Hirschsprung Seudo-obstruccin intestinal crnica Displasia neuronal (Plexos gangl alt) Hipoganglionosis (Disminucin plexos)

Causas de Estreimiento con o sin Encopresis

3) Alteraciones secundarias a trastornos metablicos o
endocrinos: Hipotiroidismo Diabetes inspida Acidosis renal Hipercalcemia Enfermedad celaca Fibrosis qustica Alergia a la protena leche de vaca

Causas de Estreimiento con o sin Encopresis

4) Medicamentos
Opiceos Fenobarbital Sucralfato Anticidos Antihipertensivos Anticolinrgicos Antidepresivos Simpaticomimticos

5) Otros (Miscelneos)
Ingestin metales pesados Abuso sexual

Tabla III Diagnstico Diferencial Clnico

Estreimiento funcional Iniciacin en R.N. Enterocolitis Encopresis Tamao Deposiciones Retardo Ponderal Ampolla Rectal Tono Esfnter Raro No Frecuente (>4 a) Grandes Raro Llena Variable Enf de Hirschsprung Frecuente Posible Rara Acintadas o N Frecuente Vaca Elevado

Diagnstico Diferencial de Constipacin por Edad

Tabla IV Lactantes < de 1 ao Enf de Hirschsprung Malformaciones congnitas anorectales Trastornos neurolgicos Encefalopatas Anomalas de columna espinal Fibrosis qustica Causas metablicas Envenenamiento por metales P Medicamentos Lactantes > de 1 ao Constipacin funcional Causas orgnicas Enf de Hirschsprung Causas Metablicas Hipotiroidismo, hipercalcemia, hipok, diabetes inspida, diabetes mellitus F. Qustica Trauma md. esp. Neurofibromatosis Medicamentos Abuso sexual Enteropata gluten

Anamnesis y Exmenes Fsicos del Paciente con Constipacin Crnica con o sin Encopresis

1. Estado general
Caractersticas de las deposicin Historia familiar de constipacin Edad de inicio de constipacin Edad de introduccin de leche de vaca Hbitos de alimentacin personal, familiar Historia de escurrimiento fecal Presencia de dolor ano-rectal Sntomas de enuresis, antec. de ITU

Anamesis y Exmenes Fsicos del Paciente con Constipacin Crnica con o sin Encopresis

2. Exmenes Fsicos
Peso-Talla, exmenes abdominales Exmenes del perine, regin perineal Exmenes zona lumbo-sacra Tacto rectal Examen neurolgico acucioso

Constipacion cronica funcional

ENFERMEDAD DE HIRSCHSPRUNG

S.DE MICROCOLON IZQUIERDO

FIBROSIS QUISTICA:

Estreimiento Crnico
Esquema Teraputico

A. Entrevista
1. 2. 3. 4. 1. 2. Explicar Desdramatizar - restaurar la confianza Corregir errores: diettica Reaprender hbito de defecacin Enemas de fosfatos hipertnicos PEG oral Objetivos Medios Reglas higinicas-medidas dietticas Laxantes osmticos, lubricantes, etc.

B. Obtener un recto vaco

C. Instaurar tratamiento a largo plazo

Constipation Delayed or difficult defecation for >2 weeks 1

-History -Physical examen -Occult blood (If Indicated) 2

from 21 Condition Abnormal T4, TSH, Ca, Pb 23 Yes Evaluate furhter 24

to 19

Yes Rectal biopsy 3 No Sweat test 6 Yes -Evaluate further -Specialty consultation 9 Hirschprung desease? 5 Yes Surgical magement 7

Delayed Passage of Meconium? 4

Question

Action Consultation whit Pediatric Gastroenterologist 25 No No -T4 -Celiac disease -TSH antibodies -Calcium -Sweat test (if not already done) No Exclusively breast-fed >2 wk old? 10 Yes Hirschsprung Disease? 30 Probably normal 13 12 Yes Rectal manometry And/or biopsy 31 29 No Has previous Treatment been Suficient? 26 Treat vigorously 27 Treatment Efective? 28

Are there any read flags? e.g. Fever, vomiting, bloody diarrhea, Failure to thrive, anal stenosis, Tight empty recum, Impaction, Distension? 8

Functional constipation 11

Treatment: -Education -Diet (prune, other juices And fruits, fluids, verify formula preparation)

Treatment Efective? 14 No Medication: -Lactulosa or Sorbitol -Malt extract -Corn Syrup -Occasional glycerin suppository 15

Surgical management 33

Yes

Positive for Hirschsprung Disease? 32 No Consider other test: -Barium -MRI -Other metabolic test 34

-Re-assessment -Adherence? -Re-education 16 Treatment Efective? 18

No

Treatment Efective? 17 Yes Maitenance therapy 19

Yes

Abnormal 35

No

Treat accordingly 36

Re-evaluate 37

-T4 -TSH -Calcium

-Celiac disease antibodies -Sweat test 21

Relapse? 20 No -Wean -Observe

An algorithm for the management of constipation in infant less than 1 year of age.
from 28

To 23

22

J Pediatr Gastroenterol Nutr, Vol 43, N 3, September 2006

from 21 Constipation Delayed or difficult defecation for > 2 weeks 1 -History -Physical examen -Occult blood (If Indicated) 2

Condition Impacted? Excess retention? Question 22

Yes

Are there Any red flags? e.g., fever, vomiting, bloody diarrhea, Failure to thrive anal stenosis, Tight empty rectum? 3 No Functional constipation 5

Action

Abdominal x-ray 23 No Excess Stool? 24 Yes

Evaluate further 4

Transit time study Yes 7 Is there Fecal impaction? 6 Normal

Abnormal 25

Disimpact with oral or rectal medication

-T4 -Celiac disease -TSH antibodies -Calcium (if not already done) Consider trial of milk-free diet 26

Soiling 27 -Behavioral modification -Psych evaluation/Rx 29 -Reassurance -Observation 30

Effective? 8

Yes

Functional constipation Without impaction 9

Hirschsprung Disease? 28 No Rectal manometry And/or biopsy 31

Treatment: -Education -Diet - Oral medication - Dairy - Close follow-up 10 -Re-assessment -Adherence? -Re-education -Different medication? 12 Yes Treatment Efective? 13 No Blood tests: -T4 -Celiac disease -TSH antibodies -Calcium -Lead 16 Abnormal T4, TSH, Ca, Pb? 18 Yes 17 Evaluate further Relapse? 15 Maintenance therapy 14 No Treatment Efective? 11 Surgical management 33

Yes

Positive for Hirschsprung Disease? 32 No

An algorithm for the management of constipation in children 1 year of age and older J Pediatr Gastroenterol Nutr, Vol 43, N 3, September 2006

Consider time-limited Rx with: -PEG solution -Bowel training -Stimulant laxatives -Intensive psych -Biofeedback 34

No

Treatment Efective? 35

Yes

-Wean -Observe

Consider other test -MRI of spine -Barium enema -Anorectal -Full-thickness biopsy manometry -Other metabolic test -Colonic manometry -Psych evaluation/Rx -Transital time -Inpatient observation 38

-Maintain Rx -Wean 36

Yes

Relapse? 37 No Observation 40

19

Consultation whit Pediatric Gastroenterologist 20

Has previus Treatment been sufficient? 21

Yes

Abnormal 39

No

To 22

Treatment

41

Re-evaluate

42

Medications for use in treatment of constipation

Laxatives Dosage Side effects Notes

Osmotic
Lactulose* 1-3 ml./Kg/day in divided doses; available as 70% solution. Flatulence, abdominal cramps; hypernatremia has been reported when used in high dosage for hepatic encephalopathy; case reports of nontoxic megacolon in elderly. Same as lactulose Synthetic disaccharide. Well tolerated long term.

Sorbitol* Barley malt extract* Magnesium hydroxide*

1-3 ml./kg/day in divided doses; available as 70% solutions. 2-10 ml./240 ml. of milk or juice. 1-3 ml./kg/day of 400 mg/5ml.; available as liquid, 400 mg/5ml and 800 mg/5ml., and tablets.

Less expensive than lactulose. Unpleasant odor. Suitable for infants drinking froom a bottle.

Infants are susceptible to magnesium poisoning. Overdose can lead to hypermegnesemia, hypophosphatemia and secondary hypocalcemia.

Acts as an osmotic laxative. Releases cholecystokinin, witch stimulates gastrointestinal secretion and motility. Use with caution in renal impairment.

Magnesium citrate*

<6 years, 1-3 ml/kg/day; 6-12 years, 100-150 ml/day; >12 years, 150-300 ml/day; in single or divided doses. Available as liquid, 16.17% magnesium.

Infants are susceptible to magnesium poisoning. Overdose can lead to hypermagnesemia, hypophosphatemia and secondary hypocalcemia.

Medications for use in treatment of constipation

Laxatives Dosage Side effects Notes

PGG 3350

Disimpaction: 1-1,5 g/kg/day for 3 days.

Superior palatability and children Safety studies necessary before widespread use is recommended in infants.
Risk of mechanical trauma to rectal wall, abdominal distention or vomiting. May cause severe and lethal episodes of hyperphosphatemia, hypocalcemia, with tetany. Some of the anion is absorbed, but if kidney is normal, no toxic accumulation accurs. Most side effects occur in children with renal failure or Hirschsprung disease. Information mostly obtained from use for total colonic irrigation. May require hospital admission and nasogastric tube. Softens stool and decreases water absorption. More palatable if chilled. Anal leakage indicates dose too high or need for clean-out

Osmotic enema Phosphate enemas

<2 years old: to be avoided; >2 years old: 6 ml/kg up to 135 ml.

Lavage Polyethylene glycol-electrolyte solution

For disimpaction: 25 ml/kg/hr (to 1000 ml/hr) by nasogastric tube until clear or 20 ml/kg/hr for 4 hr/day. For maintenance: (older children): 5-10 ml/kg/day >1 year old; not recommended. Disimpaction: 15-30 ml/yr of age, up to 240 ml daily. Maintenance: 1-3 ml/kg/day.

Difficult to take. Nausea, bloating, abdominal cramps, vomiting, and anal irritation. Aspiration, pneumonia, pulmonary edema, Mallory-Weiss tear. Safety of long-term maintenance not well established. Lipoid pneumonia if aspirated. Theoretical interferance with absorption of fat-soluble substances, but there is no evidence in the literature. Foreign-body reaction in intestinal mucosa

Lubricant Mineral oil*

Medications for use in treatment of constipation

Laxatives Dosage Side effects Notes

Stimulants

Abdominal pain, cathartic colon (possibility of permanent gut, nerve, or muscle damage).
2-6 yeras old: 2,5-7,5 ml/day; 6-12 years old: 5-15 mlk/day Available as syrup, 8,8 mg of sennosides/5 ml. Also available as granules and tablets. >2 years old: 0,5-1 suppository 1-3 tablets per dose. Available in 5 mg tablets and 10 mg suppositories. Idiosyncratic hepatitis, Melanosis coli, Hyperthropic osteoarthropathy, analgesic nephropathy.

Increased intestinal motility.

Melanosis coli improves 4-12 mo after medications discontinued.

Senna

Bisacodyl

Abdominal pain, diarrhea and hypokalemia, Abnormal rectal mucosa, and (rarely) proctitis. Case reports of urolithiasis. No side effects.

Glycerin suppositories

* Adjust dose to induce a daily bowel movement for 1 to 2 months.

J Pediatr Gastroenterol Nutr, Vol 43, N 3, September 2006