Paediatric constipation: Guidelines for referral to a paediatric surgeon

The objective of this paper is to present guidelines that were developed by the Canadian Association of Paediatric Surgeons for referring paediatric patients with constipation to a paediatric surgeon.

DEFINITION

Constipation is best defined as the symptomatic or difficult passage of stools. This definition shifts the focus away from the number of bowel movements, and expands the spectrum of constipation to include problems such as overflow incontinence, rectal and abdominal pain, rectal bleeding and prolapse.

REFERRAL BASIS

While paediatric surgeons may be involved in the general management of constipation, most referrals to them are based on the suspicion of Hirschsprung disease (HD). Despite concerns about HD, its incidence among constipated children who are otherwise well is less than 5%. Moreover, the incidence of HD rapidly diminishes after the first year of life.

The overwhelming majority of constipated children suffer from functional constipation – a vicious cycle of pain on defecation, fecal retention and chronic rectal distention. Functional constipation often has significant dietary, developmental and psychosocial causes. Its management is necessarily multifaceted with long term, consistent care involving some of the following interventions: enemas, laxatives, dietary manipulation, behavioural changes and psychosocial intervention.

HD VERSUS FUNCTIONAL CONSTIPATION

Several distinguishing features between HD and functional constipation can be used to assess the appropriate direction for referral. Features of classic HD and functional constipation are presented in Table 1.

Table 1:

Features of Hirschsprung disease versus functional constipation

Feature	Hirschsprung disease	Functional constipation
Age of onset	Infancy	Usually after toilet learning
Meconium passage	More than 24 h after birth	Within 24 h of birth
Prematurity	Rare	No effect
Symptoms (rectal bleeding, abdominal pain)	Rare (unless enterocolitis)	Common
Stool calibre	Small	Large (often plugs toilet)
Weight loss or failure to thrive	Possible	Rare
Enterocolitis*	Yes	Never
Behavioural, dietary or family problems	No	Common
Soiling	Very rare	Common
Fecal impaction in ampulla	No	Common
Anal fissures	No	Common

^*Suggested by the presence of a fever; abdominal distension; and foul, watery, explosive and occasionally bloody diarrhea after rectal examination

REFERRAL GUIDELINES

Based on the discussion above, the following children should be referred to paediatric surgeons for further investigation of HD:

• full term newborns with delayed meconium passage (more than 24 h after birth);

• infants with significant constipation or enterocolitis; and

• older children only if they present with failure to thrive or very atypical, intractable constipation.

The overwhelming majority of constipated children do not require investigations. In the three situations listed above, referral to a paediatric surgeon is preferable before further investigations because the choice and interpretation of investigations are best achieved in consultation between the paediatric surgeon and the radiologist or paediatric gastroenterologist.