Summary

Dr. YK Amdekar, through the following cases, explains why constipation should never be brushed off as a minor issue. The common problem could have varied diagnoses, sometimes requiring a more proactive approach rather than just diet and lifestyle interventions.

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Case 1

A two-year-old child presented with history of progressive abdominal distension and constipation since early infancy. It was gradually getting worse. He had poor appetite and had lost weight over last one year. There was no vomiting though he had occasional episodes of diarrhoea and had no other symptoms.

His development (milestones) was normal. He was breastfed during the first 6 months followed by the introduction of complimentary feeds. It is chronic progressive constipation starting early in life. An infant on exclusive breastfeeding never suffers from constipation and hence it is certainly a pathological disorder.

Diagnosis

1. Abdominal distension with constipation without vomiting suggests chronic colonic obstruction.
2. Prolonged constipation may lead to occasional diarrhoea as stagnated excreta promotes infection.
3. Physical examination revealed marked abdominal distension loaded with faeces.
4. Per-rectal examination led to ribbon like stool coming out indicating narrow colonic passage leading to obstruction.

This is typical of congenital megacolon – Hirschsprung disease. It is due to the absence of nerve cells in the muscles of the colon because of which the colon can’t evacuate stool. Diagnosis can be confirmed by barium enema and rectal biopsy and the condition can be managed surgically.

An exclusively breastfed infant never is constipated though stooling may be infrequent but soft. Chronic intestinal obstruction at that age is due to congenital megacolon. One may be able to suspect it even close to birth because of delayed passage of meconium. Normally meconium is passed within first 24 to 48 hours.

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Case 2

A two-year-old child presented with gradually progressive abdominal distension and constipation since early infancy. He was gaining weight well though was short in height. He was lethargic, not active, and had delayed milestones. At two years of age, he was not able to speak even a few words.

Physical examination showed a dull looking child with puffiness of face, dry skin, abdominal distension, and umbilical hernia. Per rectal examination was normal. This child besides being chronically constipated, has delayed development and lethargy. It suggests congenital hypothyroidism or cretinism.

This case is similar to the previous one but there are many subtle differences.

1. A child with congenital megacolon fails to gain weight and is mentally normal, while a hypothyroid child fails to gain height and is mentally subnormal.
2. Both conditions can be suspected within the first 2 days of birth by delayed passage of meconium.  In case of congenital megacolon, meconium passage is delayed because of colonic obstruction while in hypothyroidism, it is due to the sluggishness of the intestinal muscles and so poor peristalsis.

Both conditions should be suspected early in life to avoid permanent damage. It is most important in case of hypothyroidism as even a small delay in diagnosis and treatment may lead to permanent brain damage. In fact in most centres in the country, cord blood is tested for TSH to diagnose congenital hypothyroidism so as to prevent permanent brain damage. Incidence of congenital hypothyroidism is 1 in 2500 births and it is very high.

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Case 3

A two-year-old child presented with gradually progressive constipation since 9 months of age. He was consuming one litre of milk every day but was reluctant to eat solid food. His weight gain had slowed down in the second year though he was very active and alert. Prior to the development of constipation, he used to pass normal soft stools.

Physical examination showed mild abdominal distension but no other abnormalities. Constipation in this child had started later in the first year of his life and had been slowly progressive without much disturbance to the child’s health and activity. Thus, it is not likely to be due to any defect or disease but the result of poor eating habits.

He has good appetite but his intake is restricted only to milk. This is because of feeding bottle addiction as he would consume 6-8 ounces of milk at least twice through the night while half asleep. Further attempt to force-feed the child by the mother had made this child stubborn and he would just starve and cry for milk.

Thus, the sole cause of constipation in this child is faulty eating habits due to bottle addiction. This child would not improve unless his habits are changed. Temporary stool softeners may be necessary. It is important to cultivate ideal eating habits right from 6 months of age.

At that age, the infant is eager and ready to put anything in his mouth- it is a normal reflex. By about one year of age, most infants develop addiction either to breast or bottle feeding and this is the time to wean off gradually. If not done at that right time, the child refuses to eat solid food and gets hooked on to milk feeds only. Further force-feeding should be always avoided. It is best to allow the child to starve but not to offer milk more than 2-3 times a day.

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Case 4

A five-year-old child presented with gradually progressive constipation over the last 2 years. Initially he would pass hard stools though gradually, the frequency reduced to once in 2 to 3 days and the stool was getting more difficult to pass with pain and occasional stool smeared with blood. He had no other significant symptoms. His appetite was average and so was his weight. He was active and playful.

Physical examination did not reveal any significant abnormality. Constipation in this child has started around 3 years of age and had been very slowly worsening but without significant disturbance to his health or activity levels. Thus, it is unlikely to be due to defect or disease.

On direct questioning, it was found that his diet was imbalanced as it contained very little fiber. He also drank little water. He was often consuming “junk” food and had poor intake of vegetables and fruits. This is known as habitual constipation.

In addition, he would have to rush to school in the morning without passing stools and would withhold stool in school due to unclean toilet. This worsened his constipation. His diet needed drastic change and he should make a habit of passing stool every morning. Western toilet is not ideal to pass stools easily as against Indian type of squatting that maintains the anorectal position straight, thereby facilitating easy expulsion of stool.

Such constipation is a symbol of modern civilisation. This case is similar to the previous one as eating habits came in the way of constipation in both these children. Parents are totally responsible for inculcating wrong eating habits in early childhood. Management of constipation in such children revolve around parental cooperation to change habits. However it is ideal to ensure right eating habits right from one year of age, Otherwise habits die hard.

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Case 5

A 10-year-old child presented with constipation and abdominal pain off and on for the last year. His stooling pattern would vary in frequency and consistency and also the timing of passing stools. Most of the time he would tend to be constipated with occasional normal stool. He also had abdominal pain that also varied in frequency and severity with irregular patterns. His appetite was average and he had not lost weight. His diet was essentially normal and so was his water intake.

Physical examination did not reveal any significant abnormality. Constipation in this child obviously was not due to any defect or disease but was also not a result of poor diet or toilet habits. On direct questioning, it was realised that this child was always stressed and worried about his performance in every field.

This is typically referred to as functional constipation. It is a result of gut-brain interaction. It is now well known that intestines govern brain emotions. If one sees something frightful, intestines cramp first before the brain realises danger. When one goes to attend an examination or a similar stressful event, one gets an urge to use the toilet once more.

And finally in colloquial language, we use the term – gut feeling that is superior to the brain feeling. Intestinal complaints are most common due to such functional disorders and they may present with a change in bowel pattern and abdominal pain. Such a child as well as the parents need counselling and if necessary, psychological help.

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Case 6

A 10-year-old child presented with episodes of constipation, vomiting, and abdominal distension three times over the last 6 months. Each time, he received conservative treatment with IV fluids and rest to intestines that helped him recover within 3 to 4 days.

In between these episodes, he did not have any symptoms referable to abdomen but had poor appetite, felt generally weak and had lost 2 kg weight over the last 6 months. Physical examination during the last episode showed abdominal distension with poor peristalsis and mild tenderness without any lump in the abdomen.

It suggested intestinal obstruction. Recurrent episodes of intestinal obstruction with intervening periods of feeling unwell and loss of weight indicated persistent slowly progressive disease with intermittent symptoms of intestinal obstruction. It favours a diagnosis of intestinal Tuberculosis. Barium meal would demonstrate narrowing of intestinal segments and biopsy may confirm diagnosis of tuberculosis.

Intestinal tuberculosis affects submucosa and not mucosa and hence does not present with diarrhoea. As disease progresses, attempt at natural healing leads to fibrosis of affected submucosal lesion resulting in partial intestinal obstruction. It may be relieved temporarily with conservative treatment only to recur again. Occasionally, constipation may alternate with loose stools due to transient mucosal inflammation though constipation is the major symptom in such cases.

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Case 7

A 10-year-old child presented with recurrent episodes of constipation, abdominal distension, and vomiting three times over the last one year. Each time, he would recover with conservative treatment and in between episodes, he would be fully normal, and had gained weight and remained active.

Two years prior to these episodes, he had undergone abdominal surgery for Meckel's diverticulum. Physical examination during the last episode showed signs of intestinal obstruction. As this child has remained well during intervening period, it looks like a mechanical problem rather than any other cause. Thus it may be due to the development of adhesions following previous surgery. Such a child may need re-exploration though with a possibility of recurring adhesions.

This case is similar to previous one except that this child has been normal in between episodes unlike the previous child who was unwell during the intervening period. It clearly indicates that this child has recurrent problems with recurrent symptoms whereas the previous child had persistent problem with recurrent symptoms.

Thus, it is important to differentiate persistent from recurrent problems though both may present with recurrent symptoms. Sickness or wellness during intervening period helps to differentiate the two conditions.

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Case 8

A 10-year-old child presented with constipation and abdominal pain over the last two months. A year ago, he was diagnosed to be suffering from inflammatory bowel disease and was on treatment for the same. His main symptoms then were loose stools with mucus and abdominal pain. His disease was partially controlled with anti-inflammatory drugs and diet modification.

Physical examination showed abdominal distension with colon loaded with faeces. It is clear that constipation in this child should be related to his pre-existent inflammatory bowel disease. It may be aggravated by drugs prescribed for IBD or low fiber diet and/or poor intake of water.

However, one must rule out any evidence of stricture formation due to intestinal inflammation that may need surgical intervention. It can be confirmed by an intestinal imaging study. This case illustrates the possibility of constipation in diseases that generally present as loose stools such as inflammatory bowel disease or irritable bowel syndrome. On the other hand, diseases that present with constipation as the major symptom may also present with loose stools as in the case of intestinal tuberculosis or Hirschsprung's disease.

In summary, constipation may present with varied causes. Some of them may just need modification of diet or lifestyle while others require specific interventions to cure it. Early diagnosis and treatment would avoid long-term damage. Thus constipation should not be taken lightly and every attempt must be made to find right cause. Laxatives or stool softeners are only temporary measures till the problem is permanently solved.

To understand what the common red flags are while dianosing the underlying cause of constipation in children, read 'Constipation in children: What is the solution?' Dr. YK Amdekar

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.