Download Constipation and Abdominal Pain

Constipation and
Abdominal Pain
Jennifer Maupin, RN, CPNP-PC
Gastroenterology, Hepatology
and Nutrition
Guideline Resources, Constipation:
•Tabbers MM, DiLorenzo C, Berger MY, et al.
Evaluation and treatment of functional constipation
in infants and children: Evidence-based
recommendations from ESPGHAN and
NASPGHAN. J Pediatr Gastroenterol Nutr 2014;
58:258-274.
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Guideline Resources, Abdominal
Pain:
•Vandenplas Y, Rudolph CD et al. Pediatric
gastroesophageal reflux clinical practice
guidelines: Joint recommednations of the North
American Society for Pediatric Gastroenterology,
Hepatology, and Nutrition (NASPGHAN) and the
European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition (ESPGHAN). J Pediatr
Gastroenterol Nutr 2009; 49:498-547.
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Constipation
Definition of Functional Constipation
In the absence of organic pathology, 2 or more
of the following symptoms in a child with a
developmental age <4 years
•<2 defecations per week
•At least 1 episode of incontinence per week in a child that
was previously potty trained
•History of excessive stool retention
•History of painful or hard bowel movements
•Presence of a large fecal mass in the rectum
•History of large-diameter stools that may obstruct the
toilet
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Definition of Functional Constipation
•In a child with a developmental age >4 years and
insufficient criteria for irritable bowel syndrome:
•<2 defecations in the toilet per week
•At least 1 episode of fecal incontinence per week
•History of retentive posturing or excessive volitional stool
retention
•History of painful or hard bowel movements
•Presence of a large fecal mass in the rectum
•History of large-diameter stools that may obstruct the
toilet
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Assessment
•History
‐Onset of symptoms
‐Stool consistency (Bristol Stool Scale)
‐Stooling pattern, encopresis
‐Blood in Stool (not unusual with passage of hard stool)
‐Abdominal pain
‐Appetite/weight
‐Family history of GI problems including constipation
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•Available on-line:
•www.gutsense.org
•(better than asking,
“what does your poop
look like?”)
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Red Flags
•Weight loss, poor linear growth
•Onset of symptoms in infants <1 month old (ask
about passage of meconium at >48 hours of life)
•Blood with passage of soft stool
•Evacuation of explosive stools after withdrawal of
the examining finger on digital rectal exam
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Differential Diagnosis
‐Celiac disease
‐Hypothyroidism, hypercalcemia, hypokalemia
‐Diabetes mellitus
‐Dietary protein allergy (milk)
‐cholinergics, antidepressants, chemotherapy, heavy metal
ingestion (lead)
‐Vitamin D intoxication
‐Botulism
‐Cystic fibrosis
‐Hirschsprung’s disease
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Differential Diagnosis
‐Anal achalasia
‐Colonic inertia
‐Anatomic malformations (imperforate anus, anal stenosis)
‐Pelvic mass (sacral teratoma)
‐Spinal cord anomalies, trauma, tethered cord
‐Abnormal abdominal musculature (prune belly, gastroschisis,
Down syndrome)
‐Pseudoobstruction (visceral neuropathies, myopathies,
mesenchymopathies)
‐Multiple endocrine neoplasia type 2B
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Red Flags
Onset at <1 month of age
Passage of meconium >48 hours of life
Family history of Hirschsprung’s Disease
Ribbon stools
Blood in the stools in the absence of anal fissures or with
passage of soft stools
Failure to thrive (poor linear growth, poor weight gain)
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Red Flags
Fever (infection? Inflammation?)
Bilious vomiting (obstruction?)
Abnormal thyroid gland (thyroid dysfunction?)
Severe abdominal distention (obstruction?)
Perianal fistula (IBD?)
Abnormal position of anus
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Physical Exam Red Flags
Absent anal or cremasteric reflex (anal reflex often absent in
chronic constipation)
Decreased lower extremity strength/tone/reflex (spina bifida?)
Tuft of hair on spine (spina bifida?)
Sacral dimple (spina bifida? tethered cord?)
Gluteal cleft deviation
Extreme fear during anal inspection (abuse?)
Anal scars (surgical history? Abuse?)
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Diagnostic Testing
•Digital rectal exam: perform based on history
•X-ray (KUB): only needed if fecal impaction is
suspected or physical exam (DRE) is not possible
•Colonic Transit Study (sitz marker test): only useful
for evaluating for slow colonic transit
•Anorecal manometry: only useful in evaluation of
HD and dyssynergia. If no RAIR (rectoanal
inhibitory reflex), suction biopsy should be
performed to evaluate for HD.
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Diagnostic Testing
•Colonic manometry: evaluates colonic dysmotility,
recommend screening for colonic transit before
performing manometry
•MRI of the spine: if tethered cord or other
neurologic abnormalities suspected
•Colonic Scintigraphy: useful in measuring colonic
motility in children with slow transit constipation.
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Diagnostic Testing
•Routine laboratory testing is not recommended
•If suspected, test for:
‐Thyroid dysfunction: TSH, T-4
‐Metabolic dysfunction: Chem 10
‐Celiac disease: Celiac panel, IgA
‐Food allergy: Immunocap
‐Inflammatory markers: ESR, CRP
‐Cystic Fibrosis: Sweat test
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Nonpharmacologic Treatment
•Current research does not support the use of:
‐Fiber
‐Hydration (fluid)
‐Physical activity
‐Prebiotics
‐Probiotics
‐Behavioral therapy
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Nonpharmacologic Treatment
•What is recommended:
‐Normal fiber intake (age based)(fiber gummies are great!)
‐Normal fluid intake (64 oz/day)
‐Normal physical activity (1 hour/day)
‐Patient education demystifying, explaining and providing
guidance for toilet training
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Pharmacologic Treatment
•Polyethylene Glycol (Miralax) (OTC)
•Enemas (equally effective) (OTC)
•Less effective then Miralax:
‐Lactulose (prescription only)
‐Milk of magnesia (OTC)
‐Mineral oil (OTC)
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Dosing Miralax
• Mix 1 capful (17 grams) with 8 oz of liquid
• DO NOT mix with milk or soda
• Consume within 15-20 minutes (not effective if
placed in a sippy cup and consumed over 8 hrs)
• Titrate dose to achieve soft, but formed stool. Go
as high as it takes.
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Laxative Regimens
•Treatment of fecal impaction:
‐Miralax 1-1.5 g/kg daily for 3-6 days
‐Enema daily for 3-6 days
•Start daily laxative regimen after completed
•Miralax is preferred
•Use lactulose, milk of magnesia or mineral oil if Miralax is
not available
•Combine therapies if a single therapy is not effective
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Expert Opinion
•Maintenance treatment should continue for at least 2
months.
•All symptoms of constipation should be resolved for at least
1 month before discontinuation of treatment.
•Treatment should be decreased gradually.
•In the developmental stage of toilet training, medication
should only be stopped once toilet training is achieved.
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Novel Pharmacologic Therapies
•Medications that have been found to be effective in
treating constipation in adults. Not currently
recommended in children:
‐Lubiprostone (Amitiza), chloride channel activator
‐Linaclotide (Linzess), chronic idiopathic constipation tx
‐Prucalopride (Resotran), serotonin 5-HT4 receptor agonist
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Surgical Treatment
•ACE (cecostomy)
The antegrade delivery of cleansing solutions enables the
patient to evacuate the colon at regular intervals, avoiding
impaction of feces and reducing fecal incontinence.
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Other Treatment Options
•Transcutaneous Nerve Stimulation (TNS)
‐TNS is a noninvasive and painless form of interferential
therapy in which 4 surface electrodes are applied to the skin
which produce 2 sinusoidal currents that cross within the
body
‐Evidence does not support the use of TNS in children with
intractable constipation.
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Prognosis of Functional
Constipation in Children
•Based on study of children referred to pediatric
gastroenterologists:
After 6-12 months:
‐50% will recover and be without laxatives
‐10% are well while taking laxatives
‐40% will still be symptomatic despite use of laxatives
After 5 years:
-50% are recovered and no longer taking laxatives
After 10 years:
‐80% are recovered and no longer taking laxatives
‐A delay in initial medical treatment for >3 months from
symptom onset correlates with longer duration of symptoms
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Online Resources
•“The Poo in You”: 6 minute video available on Youtube or
at www.gikids.org
•“I go potty”: free app with potty training tips
•Squatty Potty: www.squattypotty.com (lol unicorn)
•Pedia-lax (www.pedia-lax.com)
‐Provider resources:
•Poop journal
•Product information
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Abdominal Pain
Diagnosis
•Unless proven otherwise, all pediatric abdominal
pain is acid reflux
•If it is not GER/reflux, it is most likely constipation
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History and Physical
•Infants and toddlers:
There is no symptom or symptom complex that is diagnostic of
GERD or predicts response to therapy
•Children and adolescents:
History and physical examination may be sufficient to
diagnose GERD if the symptoms are typical
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Diagnostic Testing
•pH probe and pH/impedance probe testing
‐May be useful to correlate symptoms (eg, cough, chest pain)
with acid reflux episodes and to select those infants and
children with wheezing or respiratory symptoms in whom
GER is an aggravating factor
‐Sensitivity, specificity and clinical utility for diagnosis and
management of possible extraesophageal complications of
GER are not well established
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Diagnostic Testing
•Esophageal manometry
‐Useful to confirm a diagnosis of achalasia or other motor
disorder of the esophagus that may mimic GERD
‐Not useful to diagnose GERD
•Endoscopy and biopsy
‐Important to identify or rule out other causes of esophagitis
(eosinophilic esophagitis), and to diagnose and monitor
Barrett esophagus
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Diagnostic Testing
•Barium contrast radiology (UGI)
‐Not useful for the diagnosis of GERD
‐Useful to confirm or rule out anatomic abnormalities of the
upper gastrointestinal tract that may cause symptoms similar
to those of GERD
•Nuclear scintigraphy (gastric emptying scan)
‐Not useful for the diagnosis of GERD
‐Recommended only in individuals with symptoms of gastric
retention
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Diagnostic Testing
•Esophageal and gastric ultrasonography
‐Not recommended for the routine evaluation of GERD in
children
‐Abdominal US is useful for evaluating pyloric stenosis in
infants
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Diagnostic Testing
•Tests on ear, lung and esophageal fluids
‐Evaluation of middle ear or pulmonary aspirates for lactose,
pepsin, or lipid-laden macrophages have been proposed as
the tests for GERD. No controlled studies have proven that
reflux is the only reason these compounds appear in ear or
lung fluids, and no controlled studies have shown that the
presence of these substances confirms GER as the cause of
ear, sinus, or pulmonary disease
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Diagnostic Testing
•Empiric trial of acid suppression as a diagnostic
test
‐Expert opinion suggests that in an older child or adolescent
with typical symptoms suggesting GERD, an empiric trial of
PPIs is justified for up to 4 weeks
‐Symptom improvement does not confirm a diagnosis of
GERD
‐There is no evidence to support an empiric trial of acid
suppression as a diagnostic test in infants and young children
where symptoms suggestive of GERD are less specific
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Treatment
•Lifestyle changes
‐Infant: reflux precautions (hold upright x 20 minutes after
eating, feeding smaller volumes more frequently), elemental
formulas, thickening formula
‐Children and adolescents: Prone or left-side sleeping
position and/or elevation of the head of the bed may
decrease GER. There is no evidence to support the routine
elimination of any specific food for management of GERD. In
adults, obesity, large meal volume, and late night eating are
associated with symptoms of GERD.
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Treatment
•Pharmacologic therapies:
‐Histamine-2 Receptor Antagonists
•Tagamet (cimetidine): 10-15 mg/kg/dose 4x/day, before
meals and at bedtime
•Zantac (ranitidine): 3-5 mg/kg/dose 2-3x/day, before
meals and at bedtime
Rapid onset of action, useful for on-demand treatment.
Tachyphylaxis (tolerance) is a drawback to chronic use.
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Treatment
•Pharmacologic therapies:
‐Proton Pump Inhibitors:
•Prilosec (omeprazole): 0.7 – 3.3 mg/kg/day, 1-2x/day
•Prevacid (lansoprazole): 1.4 mg/kg/day, 1-2x/day
•Protonix (pantoprazole): 1 mg/kg/day, max 40 mg/day
•Aciphex (rabeprazole): Pediatric doses not defined
•Nexium (esomeprazole): Pediatric doses not defined
PPI’s are superior to H2RAs. No PPI has been approved
for use in infants younger than 1 year of age.
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Treatment
•Pharmacologic therapies:
‐Prokinetic therapy:
•Reglan (metoclopramide): 0.1 mg/kg/dose 4x/day
•Propulsid (cisapride): 0.2 mg/kg/dose 4x/day
•Erythromycin (eryped): 3-5 mg/kg/dose, 3-4x/day
•Bethanechol (urecholine): 0.1-0.3 mg/kg/dose 3-4x/day
•Domperidone: Pediatric doses not defined
There is insufficient evidence of clinical efficacy to justify
the routine use of metoclopramide, erythromycin,
bethanechol, cisapride or domperidone for GERD.
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Treatment
•Pharmacologic therapies:
‐Buffering agents:
•Carafate (sucralfate): 40-80 mg/kg/day, 4x/day PRN
•Sodium alginate (algin): 0.2 – 0.5 mL/kg/dose, 3-4x/day
Useful on demand for occasional heartburn. Chronic use of
buffering agents or sodium alginate is not recommended for
GERD because some have absorbable components that may
have adverse effects with long-term use
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Treatment
•Surgical therapy: Nissen Fundoplication
‐Indications for surgery
•Failure of optimized medical therapy
•Dependence on long-term medical therapy
•Pulmonary aspiration of refluxate
•Respiratory complications (asthma, frequent pneumonia)
Before surgery it is essential to rule out non-GERD causes
of symptoms and ensure that the diagnosis of chronicrelapsing GERD is firmly established.
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Red Flags
•Fever:
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Red Flags
•Fever: infection, inflammatory bowel disease (IBD)
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Red Flags
•Fever: infection, inflammatory bowel disease (IBD)
•Hematochezia:
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Red Flags
•Fever: infection, inflammatory bowel disease (IBD)
•Hematochezia: milk protein allergy (infants), IBD
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Red Flags
•Fever: infection, inflammatory bowel disease (IBD)
•Hematochezia: milk protein allergy (infants), IBD
•Weight loss:
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Red Flags
•Fever: infection, inflammatory bowel disease (IBD)
•Hematochezia: milk protein allergy (infants), IBD
•Weight loss: IBD, gastroparesis
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Red Flags
•Fever: infection, inflammatory bowel disease (IBD)
•Hematochezia: milk protein allergy (infants), IBD
•Weight loss: IBD, gastroparesis
•Localized pain, right side:
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Red Flags
•Fever: infection, inflammatory bowel disease (IBD)
•Hematochezia: milk protein allergy (infants), IBD
•Weight loss: IBD, gastroparesis
•Localized pain, right side: appendicitis
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Case Study
•Ashley, 6 year old female, 19.4 kg
‐Presenting symptoms in GI clinic:
•Constipation since infancy, currently taking Miralax ½
capful daily
•Abdominal pain for 12 months, better with Miralax, has
been taking Nexium 5 mg daily x 9 months.
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Diagnostic Evaluation
•Labs: CBC w/d&p, Chem 10, TSH, T-4, Celiac
panel, IgA, Immunocap, H. pylori stool
•Results: normal/negative except for Immunocap
showed a Class 2 reaction to milk
•KUB performed: “Moderate stool in the right colon,
transverse colon, and sigmoid colon”
•Anorectal manometry: normal, negative for HD
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Diagnosis?
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Diagnosis
Constipation
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•Plan of Care:
‐Clean out: Miralax 1 capful in 8 oz of water or juice, drink 4
oz every 15 minutes until stool comes out clear. Maintain
clear liquid diet during clean out, return to regular diet after
clean out completed
‐Daily laxative regimen after clean out: Miralax 1 capful in 8 oz
of liquid daily, may titrate up or down to keep daily stools soft
but formed
‐Trial of milk protein allergy diet
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Follow Up
•Abdominal pain persisted
‐Continue laxative regimen
‐Continue milk allergy diet
‐Increase Nexium to 20 mg daily
‐Scheduled upper endoscopy to further evaluate persistent
abdominal pain. Results: negative for Celiac disease and H.
pylori, two small ulcerations found in the stomach.
‐Imipramine and Carafate prescribed based on endoscopy
findings.
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Follow up after Upper Endoscopy
•Abdominal pain persisted
‐Continue laxative regimen
‐Continue milk allergy diet
‐Increase Nexium 20 mg, 2x/day
‐Discontinue Imipramine and start Nortriptyline
‐Continue Carafate
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Next Follow Up Visit
•Abdominal pain persisted
•Presents with new symptoms:
‐Weight loss
‐Vomiting x 3 weeks
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New Diagnosis?
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New Diagnosis
•Gastroparesis
‐Gastric emptying scan performed
•Results: showed delayed gastric emptying of a solid food
meal. (153 minutes vs. normal of 90 minutes)
•Erythromycin started, 3 mg/kg/dose, 3x/day
•No improvement in abdominal pain and vomiting
•Erythromycin increased to 5 mg/kg/dose, 3x/day
•No improvement in abdominal pain and vomiting
•Erythromycin increased to 10 mg/kg/dose, 3x/day
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Follow Up
•Abdominal pain improved but not resolved
•Vomiting resolved
•Gaining weight
•Plan:
‐KUB: showed “moderate to large amount of stool
•Repeat clean out
•Continue with all other medications, no change
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Follow Up
•Abdominal pain resolved after repeat upper
endoscopy with pyloric sphincter botox injection.
Patient was seen smiling and comfortable in GI
clinic for the first time!
‐Continued on aggressive medication regimen:
•Daily laxative (Miralax)
•Daily PPI (Nexium)
•Daily Prokinetic (Erythromycin)
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Thank you
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