Definition stools that can obstruct the toilet” Rome Criteria

Definition of
Constipation

Lack of universally accepted definition of
constipation is key concern in the studies regarding constipation. In children
it is more difficult as it depends on interpretation of symptoms by parents.
Baker et al have defined constipation as ” a delay or difficulty in defecation,
for two weeks or more and sufficient to cause significant distress to patient”.1 The Paris Consensus on
Childhood Constipation Terminology (PACCT) group defined constipation as
“occurrence of two or more of the following characteristics, for 8 weeks :2  

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·        
Fecal incontinence  >1 episode per week

·        
Large stools palpable on abdominal
examination or in the rectum

·        
Painful defecation

·        
Bowel movements <3 per week ·         Stool withholding behavior or retentive posturing ·         Very stools that can obstruct the toilet" Rome Criteria for definition of constipation The most widely acceptable definition of constipation when the study was initiated was the ROME III criteria.3,4 As per the criteria, at least two of the following should be fulfilled for at least one month for children less than 4 years of age:3 ·         Hard or painful bowel movements ·         Defecation frequency two or less per week ·         Fecal incontinence at least one episode per week after acquiring toileting skills ·         Presence of large fecal mass in the rectum ·         History of excessive stool retention ·         Large diameter stools that can obstruct the toilet Similarly two or more of the following should be satisfied for at least once per week for at least 2 months for children with developmental age of at least four years with inadequate criteria for  Irritable Bowel Syndrome.4 ·         Hard or painful bowel movements ·         Two or less defecations per week ·         Fecal incontinence at least one episode per week ·         Presence of a large fecal mass in the rectum ·         Excessive volitional stool retention or retentive posturing ·         Large diameter stools that can obstruct the toilet In 2016, the new Rome IV criteria were framed with few modifications. According to it at least two of the following should be fulfilled for at least one month for children less than 4 years of age:5 ·         Hard or painful bowel movements ·         Defecation frequency of two or less per week ·         Presence of large fecal mass in the rectum ·         Excessive stool retention ·         Large diameter stools In children who are toilet trained (but <4 years), following additional criteria may be used ·         Fecal incontinence at least one episode per week after acquiring toileting skills ·         Large diameter stools that can obstruct the toilet Similarly two or more of the following should be satisfied for at least once per week for at least 1 month for children with developmental age of at least four years with insufficient criteria for diagnosis of Irritable Bowel Syndrome and the symptoms cannot be described by any other disease.6   ·         Hard or painful bowel movements ·         Two or less defecations per week in toilet ·         Fecal incontinence at least one episode per week ·         Presence of a large fecal mass in the rectum ·         Excessive volitional stool retention or retentive posturing ·         Large diameter stools that can obstruct the toilet Epidemiology of Constipation         Studies have shown prevalence of constipation in pediatric population to range from 0.7% to 29.6%7. 3% of pediatric patients presenting to OPD have constipation.8 Also, constipation constitutes 10-25 % of patients referred to pediatric gastroenterology clinics.9   Most studies have reported no significant gender difference.9,10 It is also known to be more common in low socioeconomic status and low parental income.11 Formula-fed  infants are known to be more likely to have constipation than breast-fed infants.10,12 Diagnosis of  Constipation The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) attempted to formulate Uniform Evidence based guidelines for evaluation and management of functional constipation in 2014.13 Despite the unreliability and non-specificity of symptom description in infants and young children, history and physical examination is still the main basis of the diagnosis.     History The main points to be noted are age of onset of symptoms, frequency of defecation, consistency of stools (expressed in some scale like Bristol scale,14 Lane's modified Bristol stool form scale15 or Amsterdam infant stool scale16),status of toilet training, pain during defecation, blood in stools, Constipation associated Fecal Incontinence (CFI), retentive posturing, diet history, weight loss and nausea/vomiting. Children may display retentive posturing or withholding maneuvers in the form of standing on toes, rocking back and forth, tightening of the lower limbs and arching of the back which is often interpreted wrongly by the parents as straining.1,17–19  Age of onset less than one month indicates strong possibility of Hirschprung's disease.20 Timing of passage of first meconium should also be enquired as delay by >48 hours strongly favors
diagnosis of Hirschprung’s disease.21 Many times there would
be a precipitating factor for constipation such as a painful bowel movement,
transition of feeds from  breast feeding
to bottle feeding or beginning of toilet training, etc.22 Similarly, dietary
history, treatment history, developmental history and psychosocial history are
also important. Family history of gastrointestinal disorders (Hirschprung’s
disease, inflammatory bowel disease, celiac disease, food allergies, etc) and
diseases of other organs like thyroid, parathyroid, kidneys or other diseases
like cystic fibrosis should be enquired.

Physical examination

       
Physical examination should include 13

·        
Anthropometry to assess growth

·        
Abdominal examination (distension,
palpable fecoliths)

·        
Lumbosacral region ( sacral dimple, tuft
of hair, gluteal cleft deviation, sacral agenesis, flat buttocks)

·        
Perianal inspection ( position of anus,
fissures, skin tags, stool in the anus or undergarments)

·        
Anal wink reflex and cremasteric reflex

·        
Digital rectal examination (anal
stenosis, fecal mass). Explosive stools after withdrawal of finger suggests
Hirschprung’s disease

·        
Neuromuscular examination: Tone, power,
deep tendon reflexes

 

Digital rectal examination (DRE) in diagnosis of
constipation

       When
history and abdominal examination does not accurately identify diagnosis of
constipation, DRE can be used. Beckman et al did a study to determine accuracy
of clinical variables to identify radiographically proven constipation.23 Taking presence
of fecal material throughout colon as the radiographic definition of constipation,
it was found that stool present in rectal exam was the best discriminator
between patients with and without constipation. In the absence of palpable
abdominal fecoliths, DRE would be required to detect “fecal mass in the rectum”
which is mentioned as one of the criteria for ROME III definition of
constipation.3,4  The NASPGHAN and ESPGHAN 2014 guideline recommends
DRE for diagnosis of constipation if only 1 out of 6 criteria in Rome III is
satisfied.13

 

 

Differential Diagnosis

Although functional constipation is
the most common cause of constipation, other differential diagnosis should be
considered and should be ruled out in history and examination. The following
differential diagnosis should be considered 13

·        
Hirschprung’s disease

·        
Hypothyroidism

·        
Celiac disease

·        
Electrolyte abnormalities (Hypercalcaemia,
hypokalemia)

·        
Dietary protein allergy

·        
Diabetes mellitus

·        
Toxins/drugs

Ø  Opiates,
anticholinergics

Ø  Chemotherapy

Ø  Antidepressants

Ø  Heavy
metal ingestion (e.g. lead)

·        
Botulism

·        
Spinal cord anomalies, trauma, tethered
cord

·        
Anatomic malformations

Ø  Imperforate
anus

Ø  Anal
stenosis

·        
Vitamin D intoxication

·        
Cystic fibrosis

·        
Anal achalasia

·        
Pelvic mass (e.g. sacral teratoma)

·        
Colonic inertia

·        
Abnormal abdominal musculature ( prune
belly, gastroschisis, Down syndrome)

·        
Multiple endocrine neoplasia type 2B

·        
Pseudo obstruction (visceral
neuropathies, myopathies, mesenchymopathies)

The following alarm signs and
symptoms would help to identify presence of an underlying disease causing
constipation 6,13

·        
Passage of meconium  after 48 hours of birth

·        
Constipation starting very early in life
(<1 month) ·         Ribbon stools ·         Family history of Hirschsprung's disease ·         Failure to thrive ·         Blood in stools in the absence of anal fissures ·         Fever ·         Abnormal position of anus ·         Bilious vomiting ·         Absent cremasteric/anal reflex ·         Sacral dimple ·         Tuft of hair on spine ·         Decreased tone/strength/reflex in lower extremities ·         Anal scars ·         Extreme fear during anal inspection ·         Deviation of gluteal cleft In presence of any of the above mentioned alarm signs or in case constipation is not responding to usual treatment further work up is necessary to rule out organic causes of constipation. Role of Digital Rectal Examination (DRE) Role of DRE may be divided into following 3 headings. A. Diagnosis of Constipation The 2014 NASPGHAN and ESPGHAN guidelines tried to overview nine clinical questions regarding management of functional constipation among which one clinical question was to ascertain the role of various tests including DRE for diagnosis of constipation.13 As stated previously, "presence of fecal mass in rectum" is one of the criteria for ROME III definition of constipation which would require DRE.3,4 At least 2 of the 6 criteria should be fulfilled for diagnosing constipation by ROME III definition. So, when a child is presenting with typical symptoms of constipation, DRE may not be required for diagnosis because 2 of the remaining 5 criteria may be fulfilled so presence of fecal mass in the rectum may not necessary to evaluate. But, when a child is not presenting with typical symptoms of constipation, child may not fulfill 2 of the remaining 5 criteria so, DRE may be required to confirm fecal mass in the rectum to make the diagnosis of constipation.13 For example when a child presents to pediatric OPD with abdominal pain and no other identifiable cause on history, DRE might help in making the diagnosis of constipation. B. Differentiation between organic and functional causes of Constipation An organic cause is suspected when a child presents with one or more of the alarm signs mentioned above along with constipation. Whenever there is a suspicion of an organic cause of constipation suggested by alarm signs or symptoms or in case of intractable constipation, it warrants DRE and further evaluation.13,24 Although DRE may not always diagnose an organic cause of constipation directly, it provides supportive evidence after which further diagnostic tests may be carried out.25 Many times an organic cause of constipation like anal stenosis may be diagnosed just by DRE.26   C. Diagnosing and treating fecal impaction        Fecal impaction is defined as a hard mass in the lower abdomen identified on physical examination or a dilated rectum filled with a large amount of stool on rectal examination or excessive stool in the distal colon on abdominal radiography.13 History of CFI also points out the diagnosis of fecal impaction. 27 Although abdominal radiography may give less discomfort to the child compared to rectal examination, it consumes more time, cost and exposes to radiation.28 Abdominal radiography is regarded as nonspecific for diagnosing fecal impaction and is not recommended.13 Hence in children suspected to have fecal impaction but without history of CFI or palpable fecal mass per abdomen, DRE becomes necessary. But the 2014 NASPGHAN and ESPGHAN guidelines do not have definite recommendation on using DRE for diagnosing fecal impaction. The NICE guidelines recommend to look for fecal impaction in all cases of idiopathic constipation and to do DRE if indicated. But it is not described what the indications are. In children less than 1 year age it recommends DRE to look for fecal impaction only if it is not responding to treatment in 4 weeks. These recommendations would result in unnecessary delay in the treatment of impaction. Treatment of constipation without prior disimpaction in a child is likely to be ineffective in a child with fecal impaction.24 Treatment  In presence of fecal impaction, the first step is disimpaction.17 The most preferred agent used for disimpaction is oral Polyethylene glycol with electrolytes.29,30 Enemas although equally effective are considered more invasive can also be used if there is unavailability of polyethylene glycol.31 The next step is to start maintenance therapy.17 Among the various agents used polyethylene glycol is again the most effective one but the dose is lower than for disimpaction.32 In the absence of fecal impaction treatment is directly started with maintenance therapy. Maintenance therapy has to be titrated according to response.17 Meanwhile parents should be counseled about high fiber diet and toilet training. The gastro colic reflex is utilized and the child is encouraged to sit in toilet for defecation after each meal.33 Positive reinforcement by rewards and maintenance of bowel diary is also advised.34 Treatment is continued for at least 2 months with symptom free period of at least 1 month following which dose is gradually tapered.13 Many children require treatment for several months or years.35 Regular follow up is required to assess for relapse and to reinforce food and toilet habits. Starting maintenance therapy without disimpaction in a child with fecal impaction is unlikely to succeed and causes unnecessary distress to the child and family and increases chances of poor compliance.17 Utilization of DRE DRE seems to be underutilized in clinical practice.36 A study by Gold et al showed that 77% of children referred to Pediatric Gastroenterology did not undergo prior rectal examination.25 Another study performed by Scholer et al showed DRE was done in only 5% of children presenting with acute abdominal pain in Clinic or emergency.37 Possible reason for this underutilization could be physician not being comfortable with the procedure, excess apprehension of the child and risk of ruining physician-child relationship.25,36 Another possible reason could be underestimation of fecal retention by the physician as fecal impaction may often have subtle and nonspecific presentation .38 Usefulness of DRE Though there have been studies on utilization of DRE, there are no studies demonstrating actual usefulness of DRE. Hence it is difficult to comment on what proportion of cases is likely to be missed if DRE is omitted in routine evaluation. In 2014 NASPGHAN and ESPGHAN guidelines, DRE is recommended for diagnosis of constipation if only one of the ROME III criteria is present leading to doubt in the diagnosis.13 The guideline also recommends DRE to evaluate underlying organic medical condition in the presence of alarm signs and symptoms or in case of intractable constipation. But the guideline does not make any comment on use of DRE for diagnosis of fecal impaction. Hence a study to demonstrate frequency of fecal impaction in DRE would tell us what proportion of DRE shows impaction and would provide a definite evidence to support use of DRE.