Definition stools that can obstruct the toilet” Rome Criteria

Definition of

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 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

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



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


Celiac disease

Electrolyte abnormalities (Hypercalcaemia,

Dietary protein allergy

Diabetes mellitus


Ø  Opiates,

Ø  Chemotherapy

Ø  Antidepressants

Ø  Heavy
metal ingestion (e.g. lead)


Spinal cord anomalies, trauma, tethered

Anatomic malformations

Ø  Imperforate

Ø  Anal

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