Transcript Approach to Encopresis - ACH Pediatric Residents

APPROACH TO ENCOPRESIS
Sept 1, 2011
Jody Patrick PGY-3
Objectives
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Define the types of encopresis
Outline the many possible etiologies, focusing on the
most common
Review key points on history and PE
Use of appropriate investigations
Discuss common treatment approaches
Have fun!
Definition: Encopresis
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Involuntary fecal soiling in adults and
children who have usually already been
toilet trained (over the age of 4)
Definition
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Subtypes:
Retentive encopresis: with constipation and overflow
incontinence (80-95%)
 Non-retentive encopresis: no constipation and overflow
incontinence
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Soil on daily basis, stools are normal consistency & form
 99% is non organic etiology
 Four subgroups:
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Never have achieved toilet training
Have toilet “phobia”
Use toileting to manipulate their environment
Irritable bowel syndrome
Prevalence
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Estimated between 1-3% of 4 year olds,
decreasing as children get older
Male : Female approx 6:1
Etiology
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Most Common Cause is Constipation
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At risk times for developing constipation include:
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Vicious cycle of painful, hard stools, avoidance of bowel
movement
Stretching of rectum/colon, decreased sensation
RAIR (Rectal Anal Inhibitory Reflex) is lost
Leakage around hardened stool (overflow)
Dietary switch to solid food
Toilet training
The start of school
Must rule out possible organic etiologies
Remember psychosocial factors as well
Diagnosis
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DSM-IV diagnostic criteria:
 Repeat
passage of feces into inappropriate places (eg
clothing or floor) whether voluntary or unintentional
 At least one such event a month for at least 3 months
 Chronological age of at least 4 years (or equivalent
developmental level)
 The behaviour is not exclusively due to a physiological
effect of a substance (eg laxatives) or a general
medical condition, except through a mechanism
involving constipation.
Diagnosis
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Important points on History:
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History
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Stool pattern: Size, Consistency, Interval, Straining, Blood
History of constipation: Age of onset
Passage of newborn meconium
History of soiling: Age of onset, Type and amount of material
Toilet training: age, difficulties
Diet history: Type and amount of food, Changes in diet, Appetite
Abdominal pain: Night pain, Missing school
Constitutional symptoms
Medications
Urinary symptoms: Day or night enuresis, Urinary tract infection
Family history of constipation
Family or personal stressors: birth of sibling, abuse
Behavioural difficulties: noncompliance, ODD, aggression, tantrums
Diagnosis
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Physical examination
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Height
Weight
Abdominal examination: distention, mass, especially suprapubic
Rectal examination: sacral dimple, position of anus, anal
fissures, anal wink, sphincter tone, rectal vault size, presence or
absence of stool in rectum, pelvic mass
Neurologic examination
Differential Diagnosis
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Retentive
Functional constipation (95 percent)
 Organic (5 percent)
 Anal causes: Fissures, Stenosis/atresia with fistula, Anterior
displacement of anus, Trauma, Postsurgical repair
 Neurogenic causes: Hirschsprung's disease, Chronic intestinal
psuedo-obstruction, Spinal cord disorders, Cerebral
palsy/hypotonia, Pelvic mass
 Neuromuscular disease
 Endocrine/metabolic causes: Hypothyroidism,
Hypercalcemia, Lead intoxication
 Drugs: Codeine, Antacids, Others
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Differential Diagnosis
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Nonretentive
 Nonorganic
(99 percent)
 Organic (1 percent)
 Severe ulcerative colitis
 Acquired spinal cord disease (i.e., sacral lipoma, spinal
cord tumor)
 Rectoperineal fistula with imperforate anus
 Postsurgical damage to anal sphincter
Investigations
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Depend on outcome of Hx & PE
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suggestive of constipation with no obvious organic
etiology, no further investigations required
 If unclear:
 consider
flat plate of abdomen
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failed conservative Rx, suspicious for organic cause or
non retentive pattern of soiling, consider:
 Bloodwork
(endocrine, metabolic)
 Barium enema (Hirschprung’s, fistulae)
 Rectal manometry, biopsy
Referral to GI or GS
Treatment
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Retentive (functional constipation)
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Standard 3 pronged approach:
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Non Retentive
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Clean Out
Maintain Soft Stools
Behavioural strategies
Address behaviours
Toilet routine
Soft bowel movement
Use of incentives
Other aids for encopresis
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Internet intervention
Psychological counselling
Treatment
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Clean Out
 From
above or below
 Enema
 Stool
softener, lubricants
 Nasogastric electrolyte solution
 Manual disimpaction in severe cases
 Avoid
stimulant laxatives
Treatment
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Maintenance with stool softeners/lubricants
 Lactulose
 PEG
3350
 Colace
 Mineral oil (>1yr)
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Can take several months to break cycle
 Goal
is one soft formed stool daily
 Distended bowel takes months to regain tone and
sensitivity
Treatment
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Behavioural strategies
 Regular
post prandial toileting times
 Limit time on toilet to 10-15 mins
 Stool diary
Treatment
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Non Retentive Encopresis
 Address
behaviour
 Is
child developmentally ready?
 Avoid toileting battles, take a break
 Address aggressive or oppositional behaviours first, may
require behavioural counselling
 Address toilet refusal: positive experiences sitting on toilet
 Scheduled
post prandial toileting times
 Maintain soft bowel movements
 Use Incentives for appropriate toileting
Other strategies
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Dietary management
Increase fibre intake
Better in maintenance therapy
 Increase fluid intake
No evidence that this actually helps
 Avoidance of constipating foods
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Internet Intervention:
Multiple small group studies using an internet based guide
for families
 Has shown improvement in fecal accidents
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www.ucanpooptoo.com
Resources, books
Beating Sneaky Poo, many, many
others….
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References
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Christophersen ER, Rapoff MA. Toileting problems in children. In: Walker CE, Roberts MC, eds. Handbook of clinical child
psychology. 2d ed. New York: Wiley, 1992;399-411
BRETT R. KUHN, PH.D., BETHANY A. MARCUS, PH.D., and SHERYL L. PITNER Treatment Guidelines for Primary Nonretentive
Encopresis and Stool Toileting Refusal American Family Physician
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Wikipedia, encopresis http://en.wikipedia.org/wiki/Encopresis
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Up to Date: Diagnosis and management of encopresis in children
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Schmitt BD. Encopresis. Prim Care 1984;11:497-511.
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Loening-Baucke V. Fecal incontinence in children. Am Fam Physician 1997;55:2229-38.