Pediatric Colonic Motility Disorders Clinical Presentation

Updated: Jul 05, 2016
  • Author: Nelson G Rosen, MD, FACS, FAAP; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
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Presentation

History

A complete birth history must be obtained, including first passage of meconium. Failure to pass meconium in the first 24-36 hours is associated with Hirschsprung disease. Any history of constipation from birth and multiple bouts of enteritis with diarrhea and distention suggests undiagnosed Hirschsprung disease. All children with such findings need both contrast enema and biopsy.

A history of meconium plug, constipation, and recurrent pulmonary issues suggests cystic fibrosis and necessitates performance of a sweat test. All children who present with rectal prolapse require sweat testing.

Children with idiopathic constipation often present with abdominal pain and distention. When the pain is in the right lower quadrant, their condition may be mistaken for appendicitis but can usually be distinguished from appendicitis on the basis of chronic issues such as delayed passage of stool and, perhaps, soiling. Such children have probably been examined by several physicians for the problem and may have been referred to a psychologist for stool-holding behavior.

Many children present with fecal impaction with or without soiling. Fecal incontinence is a common presenting complaint.

Pertinent questions in the history include ”How often does the child stool?” and ”What is the character of the stool?” Determining if the child is still wearing diapers because of accidents is important; if the child is not still wearing diapers, determining how often the child stains the underwear or has accidents is important. By the time children present to a surgeon's office, they have usually tried most commercially available laxatives and enemas, and their parents are frustrated.

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Physical Examination

Comprehensive physical examination must be done to exclude a systemic illness manifesting with ileus or other nonidiopathic causes of constipation. In otherwise healthy children with normal physical findings, the abdominal examination is the most pertinent study. The abdomen may be distended or tympanitic but is rarely tender. If the child is put at ease and if he or she can be examined well, firm stool may be palpable in the left side of the abdomen.

Rectal examination should be reserved for the end of the consultation because it often renders the child uncooperative. The rectal examination usually reveals the child's present state of cleanliness, which allows the examiner to put the presenting complaints into perspective. Look for any anatomic abnormalities, such as trauma, skin tags, fissures, fistulas, perirectal abscesses, polyps, or rashes.

Small babies may not be able to undergo digital rectal examination, and their anus should be sized with a Hegar dilator to rule out congenital stenosis. In full-term babies, the average anal diameter is 12 mm.

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