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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. Page 1 xxx00.#####.ppt 5/3/2017 3:53:25 AM 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. Page 2 xxx00.#####.ppt 5/3/2017 3:53:25 AM 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 Page 4 xxx00.#####.ppt 5/3/2017 3:53:25 AM 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 Page 5 xxx00.#####.ppt 5/3/2017 3:53:25 AM 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 Page 6 xxx00.#####.ppt 5/3/2017 3:53:25 AM •Available on-line: •www.gutsense.org •(better than asking, “what does your poop look like?”) Page 7 xxx00.#####.ppt 5/3/2017 3:53:25 AM 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 Page 8 xxx00.#####.ppt 5/3/2017 3:53:26 AM 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 Page 9 xxx00.#####.ppt 5/3/2017 3:53:26 AM 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 Page 10 xxx00.#####.ppt 5/3/2017 3:53:26 AM 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) Page 11 xxx00.#####.ppt 5/3/2017 3:53:26 AM Red Flags Fever (infection? Inflammation?) Bilious vomiting (obstruction?) Abnormal thyroid gland (thyroid dysfunction?) Severe abdominal distention (obstruction?) Perianal fistula (IBD?) Abnormal position of anus Page 12 xxx00.#####.ppt 5/3/2017 3:53:26 AM 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?) Page 13 xxx00.#####.ppt 5/3/2017 3:53:26 AM 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. Page 14 xxx00.#####.ppt 5/3/2017 3:53:26 AM 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. Page 15 xxx00.#####.ppt 5/3/2017 3:53:27 AM 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 Page 16 xxx00.#####.ppt 5/3/2017 3:53:27 AM Nonpharmacologic Treatment •Current research does not support the use of: ‐Fiber ‐Hydration (fluid) ‐Physical activity ‐Prebiotics ‐Probiotics ‐Behavioral therapy Page 17 xxx00.#####.ppt 5/3/2017 3:53:27 AM 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 Page 18 xxx00.#####.ppt 5/3/2017 3:53:27 AM Pharmacologic Treatment •Polyethylene Glycol (Miralax) (OTC) •Enemas (equally effective) (OTC) •Less effective then Miralax: ‐Lactulose (prescription only) ‐Milk of magnesia (OTC) ‐Mineral oil (OTC) Page 19 xxx00.#####.ppt 5/3/2017 3:53:27 AM 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. Page 20 xxx00.#####.ppt 5/3/2017 3:53:27 AM 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 Page 21 xxx00.#####.ppt 5/3/2017 3:53:27 AM 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. Page 22 xxx00.#####.ppt 5/3/2017 3:53:27 AM 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 Page 23 xxx00.#####.ppt 5/3/2017 3:53:27 AM 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. Page 24 xxx00.#####.ppt 5/3/2017 3:53:28 AM 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. Page 25 xxx00.#####.ppt 5/3/2017 3:53:28 AM 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 Page 26 xxx00.#####.ppt 5/3/2017 3:53:28 AM 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 Page 27 xxx00.#####.ppt 5/3/2017 3:53:28 AM Abdominal Pain Diagnosis •Unless proven otherwise, all pediatric abdominal pain is acid reflux •If it is not GER/reflux, it is most likely constipation Page 29 xxx00.#####.ppt 5/3/2017 3:53:28 AM 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 Page 30 xxx00.#####.ppt 5/3/2017 3:53:28 AM 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 Page 31 xxx00.#####.ppt 5/3/2017 3:53:28 AM 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 Page 32 xxx00.#####.ppt 5/3/2017 3:53:28 AM 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 Page 33 xxx00.#####.ppt 5/3/2017 3:53:28 AM 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 Page 34 xxx00.#####.ppt 5/3/2017 3:53:29 AM 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 Page 35 xxx00.#####.ppt 5/3/2017 3:53:29 AM 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 Page 36 xxx00.#####.ppt 5/3/2017 3:53:29 AM 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. Page 37 xxx00.#####.ppt 5/3/2017 3:53:29 AM 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. Page 38 xxx00.#####.ppt 5/3/2017 3:53:29 AM 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. Page 39 xxx00.#####.ppt 5/3/2017 3:53:29 AM 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. Page 40 xxx00.#####.ppt 5/3/2017 3:53:29 AM 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 Page 41 xxx00.#####.ppt 5/3/2017 3:53:29 AM 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. Page 42 xxx00.#####.ppt 5/3/2017 3:53:29 AM Red Flags •Fever: Page 43 xxx00.#####.ppt 5/3/2017 3:53:30 AM Red Flags •Fever: infection, inflammatory bowel disease (IBD) Page 44 xxx00.#####.ppt 5/3/2017 3:53:30 AM Red Flags •Fever: infection, inflammatory bowel disease (IBD) •Hematochezia: Page 45 xxx00.#####.ppt 5/3/2017 3:53:30 AM Red Flags •Fever: infection, inflammatory bowel disease (IBD) •Hematochezia: milk protein allergy (infants), IBD Page 46 xxx00.#####.ppt 5/3/2017 3:53:30 AM Red Flags •Fever: infection, inflammatory bowel disease (IBD) •Hematochezia: milk protein allergy (infants), IBD •Weight loss: Page 47 xxx00.#####.ppt 5/3/2017 3:53:30 AM Red Flags •Fever: infection, inflammatory bowel disease (IBD) •Hematochezia: milk protein allergy (infants), IBD •Weight loss: IBD, gastroparesis Page 48 xxx00.#####.ppt 5/3/2017 3:53:30 AM Red Flags •Fever: infection, inflammatory bowel disease (IBD) •Hematochezia: milk protein allergy (infants), IBD •Weight loss: IBD, gastroparesis •Localized pain, right side: Page 49 xxx00.#####.ppt 5/3/2017 3:53:30 AM Red Flags •Fever: infection, inflammatory bowel disease (IBD) •Hematochezia: milk protein allergy (infants), IBD •Weight loss: IBD, gastroparesis •Localized pain, right side: appendicitis Page 50 xxx00.#####.ppt 5/3/2017 3:53:30 AM 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. Page 51 xxx00.#####.ppt 5/3/2017 3:53:30 AM 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 Page 52 xxx00.#####.ppt 5/3/2017 3:53:30 AM Diagnosis? Page 53 xxx00.#####.ppt 5/3/2017 3:53:31 AM Diagnosis Constipation Page 54 xxx00.#####.ppt 5/3/2017 3:53:31 AM •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 Page 55 xxx00.#####.ppt 5/3/2017 3:53:31 AM 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. Page 56 xxx00.#####.ppt 5/3/2017 3:53:31 AM 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 Page 57 xxx00.#####.ppt 5/3/2017 3:53:31 AM Next Follow Up Visit •Abdominal pain persisted •Presents with new symptoms: ‐Weight loss ‐Vomiting x 3 weeks Page 58 xxx00.#####.ppt 5/3/2017 3:53:31 AM New Diagnosis? Page 59 xxx00.#####.ppt 5/3/2017 3:53:31 AM 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 Page 60 xxx00.#####.ppt 5/3/2017 3:53:31 AM 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 Page 61 xxx00.#####.ppt 5/3/2017 3:53:31 AM 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) Page 62 xxx00.#####.ppt 5/3/2017 3:53:31 AM Thank you Page 63 xxx00.#####.ppt 5/3/2017 3:53:31 AM