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The Gastrointestinal Tract

A 4-year-old boy is seen by the pediatrician with the parental complaint of constipation since the child was about 6 months old. The family reports that he produces “large and hard” stools every 3-4 days. They deny nausea, vomiting, fever, change in behavior, or blood in his stools. He was born at term, voided and stooled in the first day of life, and was discharged to home on the third day of life. Subsequently he has been a healthy child and his immunizations are current. Today his temperature is 37°C (98.6°F), and his heart rate is 90. His weight is at the 75th percentile, length at the 65th percentile, and the head circumference at the 75th percentile. The abdomen is somewhat full but soft and nontender. Rectal examination reveals a large ampulla, poor sphincter tone but an intact anal wink, and stool in the rectal vault. The plain film of his abdomen is shown in the photograph. Which of the following is the most appropriate next step in management?

image

(Used with permission from Susan John, MD.)

a. Obtain a lower gastrointestinal (GI) barium study.

b. Provide parental reassurance and dietary counseling.

c. Measure serum electrolytes.

d. Order an upper GI contrast study.

e. Initiate thyroid-replacement hormone.

The answer is b. (Hay et al, pp 644-646. Kliegman et al, pp 1763-1764, 1765. Rudolph et al, pp 1386-1389, 1436-1437.) This child has a normal past history and normal growth. The radiograph demonstrates a stool-filled megacolon. Finding a dilated, stool-filled anal canal with poor tone on the physical examination of a well-grown child supports the diagnosis of functional constipation. Hirschsprung disease is usually suspected in the chronically constipated child, but the vast majority of such children with the signs and symptoms described have functional constipation. The treatment of functional constipation emphasizes dietary changes and counseling of parents regarding proper toileting behavior. Effective stool softeners are available as a second-line option. An extensive workup of this patient with lab work or radiographic studies would likely be negative and expensive, and is not indicated. Hirschsprung usually presents in infancy with increasingly difficult defecation in the first few weeks of life. Typically no stool is found in the rectum, and anal sphincter tone is abnormal. Diagnosis of Hirschsprung disease may be made with rectal manometry and rectal biopsy.

A 10-year-old boy is seen by the pediatric nurse practitioner for “bellyaches” of 2 years’ duration. He reports the pain to be dull and achy, especially in the epigastric area, predominantly at night. The family states that he occasionally vomits after the onset of pain, but has ...

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