Clinical presentation

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The functional diagnosis of constipation

Constipation, in approximately 5-10% of the patients, is a symptom of an underlying disorder. In the remaining 90-95% of the patients constipation is idiopathic. This label implies that no clear underlying mechanism explains the defecation problem. The differential diagnosis is large, but it is highly unlikely that one of these diagnoses is missed on clinical grounds, and therefore investigations should be limited and approached cautiously. The main presenting symptoms of constipation in children are a combination of a low defecation frequency and soiling or encopresis. The latter occurs several times a day and, in severe fecal retention, also at night. If specifically asked, most children will report production of a large amount of stools, which might clog the toilet with the frequency of once a week or once a month. Often, the evacuation of such large amounts of stool is preceded by an increase of soiling frequency. At physical examination in constipated children, the rectal fecal impaction might be palpated with firm abdominal scybala, but usually manual palpation of a rectal examination with abdominal palpation as well identifies the large fecal mass.5 Table 16.1 reports the prevalence of symptoms associated with constipation.

Table 16.I The reported symptomatology of childhood constipation

Clinical features

Percentages

Bowel history

Infrequent defecation

80-100

Abdominal pain

10-64

Vomiting

8-10

Anorexia or poor appetite

10-47

Abdominal distension

0-61

Passage of large stool

45-75

Passage of hard stool

58-100

Painful defecation

50-90

Psychological problems

20-62

Urinary problems

5-43

Fecal incontinence

35-96

Positive family history

9-49

Physical examination

Fissures and rectal bleeding

5-55

Rectal prolapse

0-3

Abdominal mass

30-71

Rectal mass

28-100

Percentages are adapted from references

Defecation frequency

The average neonate has a defecation frequency of between one and four times daily. Ninety-nine per cent of newborns pass the first stool within 48 h. However, newborns with low birth weights or premature infants might have a delayed passage of the first stool. Eighty per cent of infants weighing less than 2500 g pass meconium within the first 24 h of life. If birth weight declines to 1000-1500 g, the first stool will be passed after 48h in 22-60% of children. This is still within the physiological range. In large cohort studies in normal children, the stool frequency varied greatly from once daily to once every other day. Therefore, a frequency of less than three times a week is considered abnormal, but other signs of constipation are necessary

Normal anatomy and physiology of anorectal function 249

to decide on the clinical symptomatology of consti-pation.6

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Constipation Prescription

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