Date post: | 03-Jun-2015 |
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Health & Medicine |
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Constipation & Incontinencein Children
Mohamed El-Debeiky
MSc, MD, MRCSEd
Causes
• HSD
• ARM
• Idiopathic constipation
Hirschsprung’s Disease
• It is a form of chronic intestinal obstruction caused by congenital absence of ganglion cells in both the intermuscular and submucosal plexuses.
Pathologic Anatomy
• Distal Narrow Segment: Aganglionic
• Proximal Dilated Segment: Ganglionic.
• Transitional Zone: Hypoganglionic.
Extent of Aganglionosis• Short segment (75%):
Rectosigmoid.
• Long segment (20%): Descending colon.
• Total Colonic (5%): Colon and parts of small intestine.
Clinical Picture
• Age: 50% neonates, 45% up to 2 yrs,
5% > 2yrs.• Failure to pass
meconium within 48hrs
• Abdominal distension.• Constipation.
Clinical Picture
• Vomiting.
• Diarrhea (enterocolitis).
• Perforation.
• Rectal exmaination.
Differential Diagnosis
• Meconium plug, Meconium ileus, Stenotic anus.
• NEC, Sepsis, Hypothyroidism.
• Functional constipation.
• Neuronal intestinal dysplasia (NID).
Diagnosis
• Plain X-ray Abdomen.
• Barium Enema (unprepared).
• Ano-rectal manometry.
• Rectal Biopsy.
Surgical Treatment ForHirschsprung’s Disease
• Three Stages: Outdated.• Two Stages: Standard (colostomy, pull through).• One Stage: Selected cases.
Age for definitive Pull through
• 9 months: Out dated.
• 6 months: Standard.
• Neonates: Selected cases.
Type of Surgery
• Abdomino-perineal pull through.
• Trans anal pull through.
ANORECTAL MALFORMATIONS
- 1 : 4 – 5000 newborns
- Males > Females
TYPES OF DEFECTS ( classification )
MALE DEFECTS
1. Low Defects : Perineal fistulaMedian raphe fistula
Bucket handle malformationAnal stenosis Anal membrane
2. Rectourethral bulbar fistula
3. Rectourethral prostatic fistula
4. Rectovesical ( bladder neck ) fistula
5. Imperforate anus without fistula
6. Rectal atresia and stenosis
Median raphe fistula
Rectourethral fistula
FEMALE DEFECTS
1. Low defect : Perineal fistula
2. Vestibular fistula
3. Vaginal fistula
4. Imperforate anus without fistula
5. Rectal atresia and stenosis
6. Persistent cloaca
Vestibular fistulaVestibular fistula3 orifices
ASSOCIATED DEFECTSASSOCIATED DEFECTS
UrogenitalUrogenital - Most common - Most common - 20 - 20 – 45 %– 45 %- The higher the malformation the higher the incidenceThe higher the malformation the higher the incidence
Sacrum and SpineSacrum and Spine - Sacrum frequently abnormal- Sacrum frequently abnormal deformeddeformed
reduced in numberreduced in number hemisacrumhemisacrum
- Spine frequently shows - Spine frequently shows hemivertebraehemivertebrae
D.D: Functional (Constitutional) Constipation.
• Common complaint: Constipation or incontinence.
• History: Period of normal defecation followed by constipation.
• Age: from infancy to puberty.• Causes: Emotional & stress, chronic
dehydration, anal fissure, drugs (opiates & anticholinergic), hypothyroidism.
D.D:Functional ConstipationDiagnosis
• History: Personal, Family.
• Examination: Abdomen,PR
• Plain x-ray• Barium Enema• Rectal Biopsy ?
Contrast Eenema
D.D:Functional ConstipationTreatment
• Initial evacuation of retained stools by enemas.
• Regular evacuation of rectum by suppositaries.
• Stool softners.• Treatment of anal fissurs.• Dietary.• Toilet training.
Stimulant laxatives
• Senna
• Biascodyl
• Glycerine
• MoM
Surgery
CONCLUSION
• Early detection, proper diagnosis & management of constipation in children gives excellent results.
• Hirschsprung’s disease should be suspected in cases of constipation resisting ordinary treatment.
THANK
YOU