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Indian Pediatr 2010;47: 1025-1030 |
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Etiology and Clinical Spectrum of Constipation
in Indian Children |
Vikrant Khanna*, Ujjal Poddar and Surender Kumar Yachha
From the Departments of Pediatric Gastroenterology and
*Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical
Sciences, Lucknow, India.
Correspondence to: Dr Ujjal Poddar, Associate Professor,
Department of Pediatric Gastroenterology, SGPGIMS,
Lucknow 226 014, India.
Email: [email protected]
Received: October 5, 2009;
Initial review: October 22, 2009;
Accepted: December 30, 2009.
Published online: 2010 March
15.
PII: S097475590900711-1 |
Abstract
Objective: To analyze the etiology, clinical
spectrum and outcome of constipation in children.
Setting: Tertiary care teaching hospital.
Design: Retrospective chart review.
Participants: Consecutive children with
constipation from 2001 to 2006.
Inclusion criteria: Functional constipation was
designated when there was no objective evidence of any causative
pathologic condition while the rest were termed as organic constipation.
Intervention: Lactulose was started after
disimpaction with polyethyleneglycol in functional constipation cases.
Outcome measures: Clinical and etiological
profile, management, and follow-up data.
Results: 137 children (boys, 90); 117 (85%), had
functional constipation while the remaining 15% had an associated
organic disorder. Hirschsprung’s disease accounted for 6% of all
patients. Children in organic group more commonly had delayed passage of
meconium (50.0% vs 1.7%), symptoms since first month of life
(40.0% vs 1.7 %), and abdominal distension (50% vs 5%) as
compared to functional group, while fecal impaction was less common (69%
vs 20%). Besides fecal impaction, straining (35%), withholding
behaviour (27.4%), and fecal incontinence (30.8%) were other main
clinical characteristics of the functional group. In the functional
group, ‘successful outcome’ to laxatives was obtained in 95% of patients
while 10% needed rescue disimpaction.
Conclusions: Functional constipation is the most
common cause of constipation in Indian children. History of delayed
passage of meconium, presence of abdominal distension, and absence of
fecal impaction point to an organic pathology.
Key words: Child, Constipation, Etiology, Hirschsprung
disease, India, Management.
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C hildhood constipation is a common
problem that has been difficult to define because it may comprise of
diverse symptoms from delay or difficulty in defecation, sufficient to
cause significant distress to symptoms of fecal incontinence, displaying
of retentive posturing and withholding behavior, painful defecation, to
passing of stools so large that they may obstruct the toilet(1-3). In a
systematic review on epidemiology of functional constipation, the
prevalence of childhood constipation in general population varied widely
from 0.7% to 29.6% (median 10.4%)(4). It accounts for 3% of visits to
general pediatric clinics and as many as 30% of visits to pediatric
gastroenterologists(5-7). Although clinical profile of such children is
well documented from the West(5,6,8-16), the same has not been described
from the developing world. Pediatricians of this subcontinent believe that
functional constipation is uncommon in developing countries as diet of
this part of the world is rich in fibre. Hence, many cases of constipation
are subjected to detailed investigations to rule out Hirschsprung’s
Disease (HD). As there is no published study on constipation in children
from India, we studied etiology, clinical profile and long-term outcome of
this disorder.
Methods
Consecutive children with constipation, who presented
to the Pediatric Gastroenterology services at Sanjay Gandhi Postgraduate
Institute of Medical Sciences, Lucknow, India between January 2001 and
December 2006, were included in this study. Their complete case records
were reviewed in detail for an evaluation of their presenting complaints,
associated symptoms, age at presentation, duration of constipation, and an
analysis was done of their full clinical and etiological profile.
Constipation was defined as a delay or difficulty in
defecation sufficient to cause significant distress(1). Patients were
considered having functional or idiopathic constipation (FC) if there was
no objective evidence of a pathologic condition. Fecal impaction was
defined as a hard mass in the lower abdomen identified during physical
examination, a dilated rectum filled with a large amount of stool found
during rectal examination, or excessive stool in the colon identified by
abdominal radiography. Digital rectal examination was done in all children
on the first visit. Functional fecal incontinence was defined as the
involuntary loss of any amount of feces once a week or more after
attainment of toilet skills. Secondary or organic causes of constipation
were assessed in appropriate clinical settings with appropriate
investigations. A confirmatory diagnosis of Hirschsprung’s disease (HD)
was made only after rectal /colonic biopsy showed the absence of ganglion
cells. Spinal abnormalities in suspected cases were confirmed with
magnetic resonance imaging (MRI) of the spine. Barium enema, anorectal
manometry and rectal biopsy were done only in suspected cases of
Hirschsprung disease.
Children with FC were treated with a well-defined
treatment plan intended to clear fecal retention, prevent future
retention, and promote regular bowel habits. Polyethylene glycol (PEG) was
used for disimpaction at a dose of 20ml/kg/hour (reconstituted solution of
PEG) for 4 hours and repeated on successive days (up to 3 days), if
required. Children younger than 5 years, who were unlikely to drink a
large volume, were admitted for nasogastric infusion of PEG at a dose of
25 mL/kg/hour (maximum 1000 mL/hour) till disimpaction was complete.
Successful disimpaction was defined as passage of clear fluid of nearly
same colour and consistency as being used for disimpaction (PEG fluid) per
rectum and it was reconfirmed with a digital rectal examination in those
who required rescue disimpaction. After disimpaction, patients were
started on long-term lactulose (dose 1-2 mL/kg/day) to achieve daily
defecation. The dose of lactulose was adjusted to achieve the goal of one
to two soft stools per day without any discomfort. Parents were also given
information about toilet training and high fibre diet. Parents were
educated about the normal defecation process, the importance of dietary
fibre and approach to toilet training by making their child to have
several defecation trials daily, especially after each meal. After the
child had achieved regular bowel habits on a particular dose of laxatives,
he was maintained on that dose for 3 to 6 months and then gradually
tapered off.
After the initial evaluation patients were followed up
after one month and then every 3-monthly. On follow up, laxative dose was
adjusted as per response and rescue disimpaction was done if there was a
recurrence of fecal impaction.
The clinical outcome was assessed only after 3 months
of laxative therapy. Those who had a lesser duration of laxative therapy
were excluded from the study. ‘Successful outcome’ was defined as a period
of at least 4 weeks with 3 or more bowel movements per week, without pain
during defecation and 2 or fewer soiling episodes per month with complete
resolution of all associated symptoms as retentive posturing, pain
abdomen, and bleeding per rectum(13).
Statistical analysis: SPSS statistical package
(version 13. Chicago, IL, USA) was used. Results were expressed as mean
with standard deviation or median with range, as required. Categorical
data were tested with Fisher’s exact test and continuous data with
independent sample t-test. P <0.05 was considered significant.
Results
During the study period, a total of 137 children with
constipation were managed. Their mean (SD) age was 59.2 (42.1) months
(range, 8 months to 14 years) and 90 of them were boys. The etiological
spectrum of constipation is shown in Table I. The majority,
117 (85%), had functional constipation (FC) while the remaining 20 (15%)
had an associated organic disorder. Hirschsprung disease accounted for 6%
of all cases of constipation and 40% of organic cases (Table II).
All patients with HD had history of delayed passage of meconium. Delayed
passage of meconium, and presence of abdominal distension were
significantly more common in organic group while fecal impaction was more
common in the functional group.
TABLE I
Etiology of Constipation in the Study subjects (n=137)
Etiology |
Number(%) |
Functional |
117 (85.4) |
Motility related organic causes |
Hirschsprung’s disease |
8 (5.8) |
Visceral myopathy |
1 (0.7) |
Congenital anomalies |
Anorectal malformation (anal stenosis) |
1 (0.7) |
Spinal cord abnormalities* |
4 (2.9) |
Neurologic disorders |
Disorders with mental retardation† |
3 (2.2) |
Spinal Muscular atrophy (SMA) type 2 |
1 (0.7) |
Celiac disease |
2 (1.5) |
* Meningomyelocele (operated) 3, Myelomalacia 1; †Cerebral palsy 3.
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TABLE II
Comparison of Clinical Features Between Children with Functional and Organic Constipation
|
Functional
(n=117) |
Organic
(n=20) |
M:F |
76:41 |
14:6 |
Age (mo)Mean (SD) |
60.8 (42.25) |
50.3 (41.2) |
Duration of symptoms (mo) |
25.3 (28.45) |
33.0 (33.7) |
Delayed passage of meconium* |
2 (1.7%) |
10 (50%) |
Bowel action/ wk, mean (SD) |
2.8 (1.8) |
2.8 (2.4) |
Straining |
41 (35%) |
4 (20%) |
Painful defecation |
24 (20.5%) |
1 (5%) |
Witholding |
32 (27.4%) |
2 (10%) |
Fecal incontinence |
36 (30.8%) |
4 (20%) |
Rectal bleeding |
29 (24.8%) |
2 (10%) |
Pain abdomen |
22 (18.8%) |
4 (20%) |
Fecal impaction* |
81 (69.2%) |
4 (20%) |
Abdominal distention* |
6 (5.1%) |
10 (50%) |
* P values
<0.001. |
One of the two children with celiac disease who
presented with constipation had even undergone rectal biopsy elsewhere to
rule out HD. The child with visceral myopathy had two laparotomies
(elsewhere) for suspected intestinal obstruction. Laparotomy revealed
numerous diverticulae. A full-thickness ileal biopsy, taken during
laparotomy, showed features of visceral myopathy and antroduodenal
manometry showed no spontaneous MMC (migratory motor complex) up to three
hours and small amplitude MMC after octreotide. His lactulose hydrogen
breath test was suggestive of small bowel bacterial overgrowth.
Half of the children with functional constipation
had their onset of symptoms by 18 months of age. There were only 2
patients under 12 months of age in the functional group (both at 11 months
of age). Clinical parameters were compared between children who presented
by 5 years of age (n=77) and those who presented later (n=40).
Children <5 years of age had a significantly shorter mean duration of
symptoms (15.9 ± 11.4 vs 43.9 ± 40.8 months, P<0.001) and
more commonly displayed with-holding behaviour (35.1% vs 12.5%,
P<0.01) while pain abdomen was significantly more common in children
who presented to us after 5 years (10.4% vs 35.0%, P<0.01).
More than 84% of children having withholding behavior were either 5 years
or below in age. There was no significant difference between these two
groups in respect to delayed passage of meconium, mean bowel action/week,
straining, painful defecation, fecal incontinence, rectal bleeding, fecal
impaction and abdominal distension. Twenty-nine patients (24.8%) had
history of bleeding per-rectum, 6 had documented fissure, 2 had unrelated
pathology (rectal polyp), whereas rest 21 did not have any active lesion.
On comparing patients with and without fecal
incontinence (in the functional group), it was seen that fecal
incontinence was more commonly seen in boys than in girls but the
difference was not statistically significant. All other variables (as in
table II) were comparable between the two groups, except the mean
frequency of bowel movement, which was significantly less in the patients
with fecal incontinence (2.1 ± 1.3 vs 3.3 ± 1.9, P<0.01).
Pain abdomen as a symptom was more common in girls (29.3%) than in boys
(13.2%) (P < 0.05) and while painful defecation was also more
common in girls, it did not reach a level of significance.
Of the initial 117 patients with FC, 24 were lost to
follow-up and another 17 had incomplete follow-up of less than 3 months.
Thus response to therapy could be assessed in only 76 patients who had a
mean follow-up duration of 15.0 ± 16.7 months. Overall, ‘successful
outcome’ was obtained in 72/76 (95%). Only 4 patients failed to achieve
this outcome on laxatives, including one who did not show good response to
second disimpaction and later got lost to follow-up. Fourteen (18.4%)
patients had recurrence of symptoms on follow up and 8 (10.5%) of them
required rescue disimpaction after a median duration of 5.5 months (range
1.5-17 months) of the first disimpaction. As a maintenance therapy,
lactulose was changed to PEG in 14 children, 11 due to recurrence of
symptoms while on lactulose and 3 due to side effects of lactulose
(bloating and abdominal distension). It is also noteworthy that seven of
the eight patients (87.5%) who needed rescue disimpaction had history of
fecal incontinence in comparison to 21 of 68 patients (31.0%) not needing
rescue disimpaction, the difference being significant (P <0.003).
Discussion
This is the first study from India documenting the
frequent occurrence of constipation among Indian children, with functional
constipation being responsible for the majority of the cases. Studies from
the West have shown that only around 5%-10% of children with constipation
are due to organic causes(7,17). A recently published study on
constipation in children ( <2
years of age), done in primary general pediatric clinic, found organic
causes to be responsible only in 1.6% of the patients(12). Majority of our
children with consti-pation belonged to functional group, but around 15%
had an associated organic disorder responsible for it. Our study
reiterates that history of delayed passage of meconium, presence of
abdominal distension and absence of fecal impaction are pointers to an
organic pathology.
Hirschsprung’s disease, the most important organic
cause of constipation is reported in 3% of constipated children referred
to the gastro-enterologist(18) and it accounted for 6% of the constipated
children presenting to us. The possibility of HD should be considered when
there is a history of delayed passage of meconium, poor growth,
significant abdominal distension, and an empty rectal vault in spite of
palpable abdominal fecal matter(1,7,19,20). All 8 children with Hirsch-sprung’s
disease in our study had significant abdominal distension and had a
history of delayed passage of meconium. None had rectal fecal impaction,
or withholding behaviour or fecal incontinence, which are hallmarks of
functional constipation(20).
Two children in our study had celiac disease and
presented with constipation rather than diarrhea. This association of
celiac disease and constipation has also been reported previously(21,22).
It is imperative to suspect celiac disease in any case of constipation who
has failure to thrive, anemia, alternating diarrhea and constipation, or
have abdominal distension with bloating and flatulence along with
constipation(1,2).
One of the commonly seen clinical characteristic in
functional constipation is withholding behaviour and is reported in 50-60%
cases of functional constipation (1,3,13-16,20). Only 27% of our patients
exhibited this type of retentive posturing similar to 31.2% reported in a
similar retrospective study(12). This low frequency in our study could be
due to poor data retrieval or retrospective design or it could be due to
misinterpretation of symptoms. As symptoms being noted verbatim, if the
parents were not able to differentiate between the concept of retentive
posturing and what they perceived as straining (reported in 35% of our
cases but not reported by others), it is likely that many cases with
withholding maneuvers have been misinterpreted by the parents as attempts
at straining for defecation(1,13).
Many children with FC have associated fecal
incontinence and the prevalence ranges from 18-89%, but on an average it
is 40%-60% (12-14, 16). In our study, 31% of children had associated
history of fecal incontinence. The mean frequency of bowel movement was
significantly less in the patients with fecal incontinence than in those
without fecal incontinence. Most of the patients who needed rescue
disimpaction on follow up had history of fecal incontinence, pointing to
the fact that children with fecal incontinence are a subset of
constipation with more severe symptoms and may need rescue disimpaction on
follow-up(11). Others have also found fecal incontinence to be a negative
prognostic factor for a successful outcome of therapy(9,23). All our
patients were started on the treatment programme as outlined above and
‘successful outcome’ was obtained in the majority of cases, with meagre 5%
not responding adequately to laxatives mainly due to non-compliance to
dose and non-cooperation with toilet training. Similar response rates have
been previously documen-ted(13). It is important to note that mere
laxative therapy does not guarantee cure in functional constipation.
Dietary advice (reduction of milk intake and increase in high fibre
containing solid food intake) and toilet training play an important role
in the successful outcome of medical therapy. With regular follow up we
ensured compliance to high fibre diet and regular toilet training and that
is responsible for the good response noted by us.
A subset of patients with constipation may be
refractory to usual medical therapy of laxative, diet and toilet training
and one of the reasons is motility disorder. As per the motility pattern
three main types of functional constipation have been described; normal
colonic transit constipation, slow transit constipation and functional
outlet obstruction(24). The prokinetic drugs like tegaserod (not yet
approved for use in children) is useful in slow transit constipation and
biofeedback helps in functional outlet obstruction cases.
In view of retrospective nature of our study the main
limitation is that almost 35% of children with functional constipation
either were lost to follow up or had incomplete information. Hence, the
efficacy of therapy could not be assessed properly.
To summarize, functional constipation is the most
common form of constipation presenting in children in India as in the
West, though upto 15% of patients may have an organic cause in whom
history of delayed passage of meconium, presence of abdominal distension,
and absence of fecal impaction in rectum point to an organic pathology.
Patients with fecal incontinence along with constipation are a subset with
more severe disease. We hope this study will increase the awareness about
functional constipation in India and pediatricians/pediatric surgeons will
stop investigating all cases of constipation for Hirschsprung disease.
Contributors: VK: Data collection, analysis
and drafting the manuscript; UP: Protocol development, data collection and
writing the manuscript; SKY: Data collection, analysis and manuscript
preparation.
Funding: None.
Competing interests: None stated.
What is Already Known?
•
Constipation is a common problem in children.
What This Study Adds?
•
Functional constipation is the commonest cause of constipation in
Indian children. |
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