Pediatric Constipation Differential Diagnoses

  • Author: Stephen Borowitz, MD; Chief Editor: Carmen Cuffari, MD   more...
 
Updated: Feb 1, 2012
 
 

Diagnostic Considerations

The differential diagnosis of childhood constipation can be extensive and may include Hirschsprung disease (ie, congenital megacolon), spinal or neuromuscular abnormalities (eg, spinal muscular atrophy, tethered cord, Currarino triad [rectal stenosis, hemi sacrum, presacral mass], cerebral palsy [static encephalopathy]), hypothyroidism, anal stenosis, imperforate anus with fistula, anterior displacement of the anus (this is a controversial diagnosis), allergy or sensitivity to cow's milk, and celiac disease. Other conditions to consider include mitochondrial disorders, neuronal intestinal dysplasia, and prune-belly syndrome.

Fortunately, in most cases in which an underlying condition causes constipation, other stigmata of the disorder point to diagnosis. For example, constipation is rarely the only symptom of hypothyroidism.

For practical purposes, in an otherwise healthy child, the differential diagnosis of chronic constipation is Hirschsprung disease and functional constipation (not Hirschsprung disease). Although this differentiation may sometimes be difficult, numerous clues in the history and physical examination are helpful. The image below details the differences between functional constipation and Hirschsprung disease.

See also Constipation and Surgery for Pediatric Constipation and Bowel Management.

This table differentiates functional constipation This table differentiates functional constipation from Hirschsprung disease.

Differential Diagnoses

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Contributor Information and Disclosures
Author

Stephen Borowitz, MD  Professor of Pediatrics and Public Health Sciences, Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Virginia School of Medicine

Stephen Borowitz, MD is a member of the following medical societies: American Academy of Pediatrics, American Gastroenterological Association, American Pediatric Society, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Chris A Liacouras  MD, Director of Pediatric Endoscopy, Division of Gastroenterology and Nutrition, Children's Hospital of Philadelphia; Associate Professor of Pediatrics, University of Pennsylvania School of Medicine

Chris A Liacouras is a member of the following medical societies: American Gastroenterological Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD  Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

References

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  2. Borowitz SM, Cox DJ, Kovatchev B, et al. Treatment of childhood constipation by primary care physicians: efficacy and predictors of outcome. Pediatrics. Apr 2005;115(4):873-7. [Medline].

  3. [Guideline] North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in children: summary of updated recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr. Sep 2006;43(3):405-7. [Medline].

  4. Benninga M, Candy DC, Catto-Smith AG, et al. The Paris Consensus on Childhood Constipation Terminology (PACCT) Group. J Pediatr Gastroenterol Nutr. Mar 2005;40(3):273-5. [Medline].

  5. Issenman RM, Hewson S, Pirhonen D, et al. Are chronic digestive complaints the result of abnormal dietary patterns? Diet and digestive complaints in children at 22 and 40 months of age. Am J Dis Child. Jun 1987;141(6):679-82. [Medline].

  6. Loening-Baucke V. Prevalence rates for constipation and faecal and urinary incontinence. Arch Dis Child. Jun 2007;92(6):486-9. [Medline].

  7. Saps M, Sztainberg M, Di Lorenzo C. A prospective community-based study of gastroenterological symptoms in school-age children. J Pediatr Gastroenterol Nutr. Oct 2006;43(4):477-82. [Medline].

  8. Yong D, Beattie RM. Normal bowel habit and prevalence of constipation in primary-school children. In: Ambulatory Child Health. Vol 4. 1998:277-82.

  9. de Araujo Sant Anna AM, Calcado AC. Constipation in school-aged children at public schools in Rio de Janeiro, Brazil. J Pediatr Gastroenterol Nutr. Aug 1999;29(2):190-3. [Medline].

  10. Borowitz SM, Cox DJ, Tam A, et al. Precipitants of constipation during early childhood. J Am Board Fam Pract. May-Jun 2003;16(3):213-8. [Medline].

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  14. Bekkali NL, van den Berg MM, Dijkgraaf MG, et al. Rectal fecal impaction treatment in childhood constipation: enemas versus high doses oral PEG. Pediatrics. Dec 2009;124(6):e1108-15. [Medline].

  15. Miller MK, Dowd MD, Friesen CA, Walsh-Kelly CM. A Randomized Trial of Enema Versus Polyethylene Glycol 3350 for Fecal Disimpaction in Children Presenting to an Emergency Department. Pediatr Emerg Care. Jan 20 2012;[Medline].

  16. Pijpers MA, Tabbers MM, Benninga MA, Berger MY. Currently recommended treatments of childhood constipation are not evidence based: a systematic literature review on the effect of laxative treatment and dietary measures. Arch Dis Child. Feb 2009;94(2):117-31. [Medline].

  17. Corkins MR. Are diet and constipation related in children?. Nutr Clin Pract. Oct 2005;20(5):536-9. [Medline].

  18. Iacono G, Cavataio F, Montalto G, et al. Intolerance of cow's milk and chronic constipation in children. N Engl J Med. Oct 15 1998;339(16):1100-4. [Medline].

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  20. Vandenplas Y, Benninga M. Probiotics and functional gastrointestinal disorders in children. J Pediatr Gastroenterol Nutr. Apr 2009;48 Suppl 2:S107-9. [Medline].

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  24. Khan S, Campo J, Bridge JA, et al. Long-term outcome of functional childhood constipation. Dig Dis Sci. Jan 2007;52(1):64-9. [Medline].

 
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Plain abdominal radiograph that demonstrates stool throughout the colon.
This table differentiates functional constipation from Hirschsprung disease.
This unprepared single-contrast barium enema demonstrates a transition zone consistent with Hirschsprung disease.
The images illustrate normal anorectal manometry with relaxation of the internal anal sphincter in response to rectal distention.
This image delineates common withholding behaviors in young children.
Contrast enema of a patient with megasigmoid and impacted stool.
Contrast enema in a patient in whom the rectosigmoid was resected.
Position for enema administration in an infant.
Another position for enema administration.
Administration of an enema.
Incorrect enema administration. The enema is administered against stool impaction and cannot be successful.
Enema administration with a tube.
Enema with inflated Foley balloon catheter.
Administration of an enema against impacted stool.
Administration of an enema against fecal impaction.
 
 
 
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