​Kembara Xtra - Medicine - Encopresis

​Kembara Xtra - Medicine - Encopresis 
Introduction 
Voluntary or involuntary fecal soilage in an individual who has (usually) previously been toilet-trained — Age may be chronological or developmental. Age may be related to developmental or chronological age.
At least one event per month for three months Classified into functional constipation (retentive encopresis) and functional nonretentive fecal incontinence (FNRFI); both induce fecal incontinence. – No underlying organic disease – At least one episode per month for three months.
In patients using FNRFI, constipation is not an issue. The more prevalent form of constipation is functional constipation.
Incontinence of feces in adults, also known as encopresis, is a different topic.
System(s) impacted: gastrointestinal (GI) and psychological 
fecal incontinence, soiling are some synonyms for this condition.

Incidence and Prevalence 

Incidence

Males outnumber females by a ratio of 4:1 to 6:1 on average. 
Constipation is the cause of 3% of general pediatric referrals, and up to 84% of children who suffer from constipation will experience fecal incontinence at some point in their lives.
Prevalence
Occurs in one percent to three percent of children aged 4 years old.

Causes and effects: etiology and pathophysiology 

Constipation, especially when it's chronic, is the leading cause of encopresis, which leads to overflow incontinence (retentive encopresis) in 90 percent of the cases. The remaining 10% of cases are attributable to a variety of organic etiologies.
Chronic constipation with irregular and partial evacuation leads to gradual rectal distension and stretching of the internal/external anal sphincters. Chronic rectal distension leads to habituation, which results in the loss of perceiving the natural desire to defecate. Chronic rectal distension can be prevented by avoiding constipation and maintaining a healthy weight.
After some time, the retained fecal material will be surrounded by liquid or soft stool that will flow out.
In reaction to the urge to defecate, many children deliberately retain their bowel movements out of fear of experiencing discomfort or out of an obsession with maintaining their participation in group activities.
Psychological, include clutching one's stool, fear, and anxiety
- Difficulty in potty training, which may include unusual anxiety or disagreement with the parent – Reluctance to use public toilet facilities, such as those found in schools or in public areas outside of schools – Known association with sexual abuse in boys; likely comparable association in girls – Delay in the development of the child
Anatomical: – Rectal distension and desensitization – Anal fissure or painful defecation – Muscle hypotonia – Slow intestinal motility – Hirschsprung disease
– Neurofibromatosis – Pelvic mass – Anal stenosis – Anterior displacement of the anus – Postoperative stricture of the anus or rectum – Cystic fibrosis
Dietary or metabolic – Inadequate dietary fiber; excessive protein or milk intake; inadequate water intake – Hypothyroidism; hypercalcemia; hypokalemia – Diabetes insipidus; diabetes mellitus – Food allergy – Gluten enteropathy Medication side effects Dietary or metabolic – Inadequate dietary fiber; excessive protein or milk intake; inadequate water intake – Hypothyroidism; hypercalcemia; hypokalemia – Diabetes in Genetics
None is known, however there is a possibility that the risk is greater in children whose families have a history of constipation.


Risk Factors ● Male gender ● Constipation

Very low birth weight; painful bowel movements; difficulty with bowel training; social pressure related to early daycare placement; organic and anatomic causes; anxiety and depression; insufficient intake of fluid or fiber; refusal to use public restrooms; attention deficit disorder; history of abuse;

Prevention 
Education for the whole family should include potty training at the appropriate time and a focus on getting enough fluids and fiber.

Conditions That Often Occur Together 

Irritable bowel syndrome, Hirschsprung disease
Diagnostic categories include: cerebral palsy, cystic fibrosis, developmental and behavioral disorders, and urine incontinence

History of the Condition Signs and symptoms of constipation include the following: – Stools that are firm and of a large caliber – Fewer than three bowel movements per week – Discomfort or pain associated with passing stools – Refusal to pass stools – Blood on stools or in the diaper or toilet bowl – Loss of appetite – Abdominal pain that is relieved by passing stools
– Hiding when defecating before the child is instructed to use the toilet; delaying the use of the toilet – Consuming a diet that is low in fiber or fluids and high in dairy items
– Stool does not pass in the first 48 hours of life – Stool appears pasty on underclothes – Recurrent urinary tract infections

• Sudden beginning after the age of 5 years is more likely to be related with psychological trauma. • Children older than 5 years are more likely to have overlap with attention deficit disorder (ADD).
Opiate and phenobarbital use, as well as tricyclic antidepressant (TCA) medication consumption. A history of constipation in the patient's family.

The Patient's Clinical Examination 
Genital examination and digital rectal exam: perineal feeling, cremasteric reflex, and anal sphincter tone Neurologic exam of lower extremities and perineal area, with attention to S1–S4 distribution, perineal sensation, and anal sphincter tone Genital examination and digital rectal exam: Examine the patient for the presence of occult or obvious blood, anal fissures, sphincter tone, and rectal distension or impaction.

Bowel noises, percussion note (tympany), abdominal distension, and palpate for stool (more prevalent in the left lower quadrant). These are the components of an abdominal exam.

Results From the Laboratory 

The majority of cases are diagnosed through the patient's history and physical examination and first tests (laboratory, imaging).
Only employed to exclude the possibility of biological origins.
● UA/urine culture: UTI/glucosuria
Tests to evaluate thyroid function: hypothyroidism
Electrolyte panel, including calcium measurement: hypokalemia, hypercalcemia, or hyperglycemia
Abdominal plain films in the event that impaction is suspected but neither the abdominal nor the rectal exam reveals it.
Additional Examinations, as well as Other Important Factors
If a newborn does not pass meconium during the first 48 hours of life, if the newborn does not flourish, if the newborn experiences bloody diarrhea, or if the newborn vomits bile, a ganglionic megacolon should be ruled out as soon as possible.
Evaluation for cystic fibrosis should be initiated at the first sign of symptoms such as diarrhea and constipation, a rash, failure to thrive, or recurrent pneumonia. Patients who are experiencing abdominal distension or ileus need to have an evaluation to rule out the possibility of obstruction.
Patients who have constipation that does not respond to medication may benefit from diagnostic procedures or other manometric investigations.

Management 
Preventative recommendations on the ages at which children should wean themselves off of diapers and begin using pull-ups or training underwear throughout the day (the typical age at which girls become toilet-trained is 29 months, while boys reach this milestone at 31 months).
Ensure that impaction has been removed before beginning maintenance therapy.
Once stools are regular in frequency, child should sit on toilet BID at the same time each day for 10 to 15 minutes and for 10 to 15 minutes after meals. Avoid frequent and repeated rectal exams, enemas, and suppositories, especially in newborns. Once stools are regular in frequency, avoid frequent and repeated rectal exams, enemas, and suppositories. Implementing positive reinforcement for successful bowel motions is important.

Medication 

You can use oral medications, enemas, or rectal suppositories to remove the impaction, but oral agents are the least stressful. You should then begin treatment for the maintenance of the condition. No randomized controlled research have examined the different ways of disimpaction.
Suppositories containing glycerin are the most suitable alternative for newborns.

First Line
Disimpaction using polyethylene glycol (PEG) - Administer 17 grams (240 milliliters) of water or juice at a dose of 1.0 to 1.5 grams per kilogram each day for three days.
- Between 0.4 and 0.8 grams per kilogram per day for maintenance
For children older than one year, administer mineral oil at a rate of 15 to 30 mL every year of age, up to a maximum of 240 mL.
– Maintenance Dose: 1-3 mL/kg/Day, or BID If Divided
- May be made more palatable by mixing with orange juice; nevertheless, avoid giving to newborns in order to prevent aspiration pneumonia.
● The following are some examples of other maintenance schedules: - Milk of magnesia (MOM) 400 mg (5 mL): 1 to 2 mL/kg/day BID
- Lactulose 10 grams (or 15 milliliters): 1 to 3 milliliters per kilogram per day, split BID
– Senna syrup Ages 2 to 6 years: 2.5 to 7.5 mL/day divided BID; ages 6 to 12 years: 5 to 15 mL/day divided BID for a total of 8.8 g sennoside (5 mL).
- The recommended dosage of bisacodyl suppository 10 mg is half to one suppository, once or twice day.


Referral 

If the patient's symptoms have not improved after adhering to a multifactoral therapy paradigm for a period of six months, the patient should be sent to a pediatric gastroenterologist for additional examination and direction.

Extra Treatments and Medications 
therapy and treatment for problematic behaviors

Surgical Methods and Operations 

Anorectal manometry should be considered as a diagnostic tool for achalasia of the internal anal sphincter (also known as ultrashort-segment Hirschsprung disease) in patients whose chronic constipation does not respond to a combination of pharmacological and behavioral therapy. In the event that it is present, this ailment can be successfully treated in the majority of patients by means of an internal sphincter myectomy.

Alternative Medicine 

Encopresis is more likely to clear up in children with volitional stool holding who receive behavioral treatment in addition to medication at three and six months than in children who receive medication alone. This is the case when comparing medication with behavioral treatment.

There is no evidence to suggest that traditional treatment for functional fecal incontinence in children would benefit from the addition of biofeedback training.

Children who have functional fecal incontinence linked with constipation respond better to behavioral therapies in combination with laxative therapy than they do to laxative therapy by alone in terms of improvements in continence.


Admission 
● Admission criteria/initial stabilization - Ongoing contamination and repeated impaction of outpatient medical care, whether as a result of ineffective medicine or patient nonadherence – A decrease in intake that can lead to malnutrition or dehydration – Vomiting that is difficult to control or a concern for obstruction
- Involve the proper authorities if there is any suspicion of abuse.
– Inpatient treatment in the hospital together with abdominal imaging may be required to guarantee the entire expulsion of the impaction.
If the patient is unable to tolerate the treatment by mouth, this may entail the delivery of balanced electrolyte–PEG solutions directly into the patient's stomach. The determination of whether or not a treatment is effective can be aided by the use of serial abdomen films and the examination of rectal effluent.
Fluids administered intravenously in the event that the patient is dehydrated and unable to tolerate oral intake • The nursing staff is responsible for documenting stool output as well as stool character • Discharge criteria
Inpatient treatment is considered to have been successful when the patient's stools become less firm and more watery in appearance.
- Abdominal radiographs demonstrating decreased fecal loading (in comparison to a radiograph taken before therapy) in conjunction with improved serial abdominal exams

Ongoing Medical Attention 
The patient and their family should be encouraged to keep records of successful bowel movements as well as instances of soiling. Additionally, an incentive system should be implemented to encourage continuing attempts to sit on the toilet regularly.
When planning on conducting a thorough follow-up, it is essential that the patient and the clinician care team maintain an open line of communication. This is especially important following hospitalizations for procedures such as rectal disimpaction and bowel preparations.

Keep in Touch 

Follow up with a clinician once a month at first to examine the patient's stooling regimen, perform a physical exam, and tweak the home regimen as necessary to ensure the patient continues to make progress and experiences remission of symptoms.
Monitoring of the Patient
It is recommended that maintenance treatment be continued for a period of six months to two years, with visits occurring every four to ten weeks for support and to guarantee compliance; more frequent visits are recommended for children who are oppositional or anxious. Telephone or virtual visits can be utilized to modify doses and to provide ongoing encouragement.
• Impaction that occurs again should be treated as soon as possible.
Children who do not make improvement utilizing a well-designed behavior plan should be referred for more in-depth mental health examination and counseling. The focus should be on ensuring that medicine is taken as prescribed and that the child takes the initiative to visit the restroom on a regular basis.
DIET
consumption of sufficient quantities of both liquids and fiber (2) [A]. Cut back on items made from cow's milk. Try to limit your intake of bananas, grains, apples, and gelatin as much as possible.


Defecation should be explained in detail, as should the treatment plan, which should include both food and medication adjustments.
● Avoid penalties for unintended soiling.
Explain to the parents of children older than four years old how an excessive reliance on diapers and pull-ups, despite their convenience, might prolong the problem of incontinence.
If the positive method does not work, you should always try to utilize positive reinforcement for successful toilet sits and medication compliance. If the positive approach does not work, you should consider eliminating desired privileges (such as TV or video games) for noncompliance with the behavioral plan. To encourage desirable behavior in youngsters, a token economy (also known as earned privileges) can work successfully with certain of them.
Inspire participants to engage in consistent physical activity.

Prognosis 

Despite having a positive reaction, many children continue to struggle because their parents do not follow the treatment plan.
After five years of treatment, encopresis may still be present in between 30 and 50 percent of children.
Children who have been struggling with psychological or emotional issues prior to the onset of encopresis are more resistant to treatment.

Complications include colitis caused by an excessive amount of enema or suppository, perianal dermatitis, and an oral fissure.