GASTROINTESTINAL

PROBLEMS IN PEDIATRIC
Department of Pediatric
Faculty of Medicine
Tarumanagara University
2010

Departments involved to Gastrointestinal Problems

Physiology

Bio
Chemistry

Para
sitology

Histology

Anatomy

Pediatric
Gastroenterology

Community
Medicine

Micro
biology

Clinical
Pharma
cology

Patology
Nutrition

Patology
Anatomi

Clinical
Pharmacy

Gastrointestinal / digestive tract

Upper Gastrointestinal Tract
Lower Gastrointestinal Tract
Border upper-lower: ligamentum
Treitz.

Gastrointestinal / digestive tract

* Upper Gastrointestinal Tract
Esophagus, stomach (gaster), proximal
small intestine (duodenum and proximal
jejunum above ligamentum Treitz).

Gastrointestinal / digestive tract

* Upper Gastrointestinal Tract
* Lower Gastrointestinal Tract
distal small intestine (distal jejunum below
ligamentum Treitz), ileum, colon, rectum,
and anus.

Gastrointestinal / Digestive tract

Disphagia &
Regurgitasi
Emesis /
Vomiting

Common
Gastrointestinal
Problems in
Pediatric
Gastroesophageal
Reflux
Allergic gut
problems

Infantile
Colic
Abdominal
Pain
Gut
Infection

Intolerance /
Malabsorpsi
Inflamatory
Bowel Disease
Gut Bleeding
Constipation

Functional bowel disorders in children

Dysphagia ?
Regurgitation ?

Dysphagia

Problems / dificultty in swallowing

food or liquid

or Refers to the sensation of food

being hindered in its passage
from the mouth to the stomach.

Dysphagia
Act of swallowing
oral preparation phase
oral transfer phase
pharyngeal phase
esophageal phase.

Dysphagia
Causes of Dysphagia (mechanical)
Structural defect
typical cause more problems in
swallowing solids than liquids.
cause a fixed impediment to food
bolus arise from narrowing within
the esophagus (e.g. stricture, web,
tumor, etc).
Motility disoders
motility abnormalities of the
oropharynx or esophagus.

Dysphagia
Term of Dysphagia

transfer

Oropharyngeal dysphagia
dysphagia.
Esophageal dysphagia
non-transfer dysphagia.

Dysphagia
Oropharyngeal dysphagia
- Neuromuscular diseases: CVA,
Parkinsons disease, Myasthenia gravis,
etc.
- Local mechanical lesions: inflammation
(pharyngitis, absces etc), neoplasm,
congenital webs, etc.
- Upper esophageal sphincter (UES)
disoders.

Dysphagia
Esophageal dysphagia
- Motility disorders: Achalasia,
Scleroderma, Diffuse esophagea
spasm, etc.
- Intrinsic mechanical lesions : Benign
stricture (peptic, radiation), Carcinoma,
etc.
- Extrinsic mechanical lesions: Vascular
compression, Mediastinal abnormalities,
etc.

Dysphagia
Functional dysphagia
Diagnostic criteria* Must include all of the
following (Rome III)

Sense of solid and/or liquid foods

sticking, lodging, or passing
abnormally through the esophagus

Absence of evidence that

gastroesophageal reflux is the
cause of the
symptom.

Absence of histopathology-based
esophageal motility disorders

Dysphagia
Difficulty
initiating swallow
(coughing,
choking, nasal
regurgitation)
Orofaring
dysphagia

Dysphagia
Difficulty
initiating swallow
(coughing,
choking, nasal
regurgitation)
Orofaring
dysphagia

Solid food only

Food stop after swallowing

Oesophageal dysphagia
Solid or liquid food

Dysphagia
Difficulty
initiating swallow
(coughing,
choking, nasal
regurgitation)
Orofaring
dysphagia

Food stop after swallowing

Oesophageal dysphagia

Solid food only

Mechanical
obstruction

Progressive
Chronic heartburn

Peptic stricture

Intermitent
Age > 50 yr

Carcinoma

Solid or liquid food

Dysphagia
Difficulty
initiating swallow
(coughing,
choking, nasal
regurgitation)
Orofaring
dysphagia

Food stop after swallowing

Oesophageal dysphagia
Solid or liquid food

Solid food only

Mechanical
obstruction

Progressive

Intermitent

Neuromuscular disoder
Progressive

Intermitent

Chronic heartburn

Age > 50 yr

Chronic
heartburn

Respiratory
symptoms

Peptic stricture

Carcinoma

Scleroderma

Achalasia

Chest
Pain
Diffuse
esophageal
spasm

Regurgitation

The effortless movement of stomach

contents into the esophagus and
mouth.

expulsion of material from the

mouth, pharynx, or esophagus,
usually characterized by the
presence of undigested food or
blood.

Passive retrograde flow of

esophageal contents.

Regurgitation

Spitting up of food from the

esophagus or stomach without
nausea or forceful contractions of
the abdominal muscles.

Causes of regurgitation

incompeten lower esophageal

sphincter.

immature lower esophageal

sphincter (infant).

Vomiting /
Emesis ?

Vomiting / emesis
Vomiting
- Vomiting is the forceful contraction of the
stomach that propels its contents up the
esophagus and out through the
mouth
and sometimes the nose.
- or coordinated motor response of the GI
tract, abdominal and thoracic
muscles
that results in forceful
expulsion of
stomach contents

Vomiting / emesis
- Vomiting is different from regurgitation,
although the two terms are often used
interchangeably.
- Regurgitation is the return of undigested
food back up the esophagus to the
mouth, without the force and displeasure
associated with vomiting.
- The causes of vomiting and
regurgitation are generally different.

Vomiting / emesis
- Vomiting in infant and children is
frequently found and as first symptom of
infection of gastrointestinal or extra
gastrointestinal.
- Management is directed to the etiology
of vomiting.
- The use of antiemetic drugs are
indicated only for functional
disturbances of gastrointestinal
and
contraindication for
mechanical
abnormality of

Vomiting / emesis
Causes of vomiting in children

Inborn eror of metabolism

Medication (chemotherapy, erythromycin)
Increased intracranial pressure
Infection
Psychogenic
Abdominal migraine
Toxins
Labirynithtis
Adrenal insufificiency

Vomiting / emesis
Complication

Aspiration of vomit

Esophagitis

Dehydration and electrolyte imbalance

Mallory Weiss tear (small tears at lesser

curve of gastroesophageal junction).

Malnutrition or failure to thrive.

Differential Diagnosis of Emesis During Childhood

Infant
Child
Adolescent
Common
Gastroenteritis

Gastroenteritis

Gastroenteritis

Gastroesophageal
Reflux

Systemic infection

Reflux (GERD)

Overfeeding

Gastritis

Systemic infection

Anatomic obstruction

Toxic ingestion

Toxic ingestion

Systemic infection

Pertusis Syndrome

Gastritis

Pertusis Syndrome

Medication

Sinusitis/otitis media

Otitis media

Reflux (GERD)

Inflamatory Bowel
Disease

Milk Allergy

Sinusitis

Appendicitis

Otitis media/faringitis

Migraine

Psychologic distress

Pregnancy
Medication
Psychologic distress

Vomiting / emesis
Functional Vomiting (Rome III))
Diagnostic criteria : Pelajari Rome III:
The new criteria of Functional
Gastrointestinal Disoders (FGIDs)
Diagnostic Criteria for Functional
Gastrointestinal Disoders

Gastroesophageal Reflux ?

Gastroesophageal Reflux
Physiological
Gastroesophageal
Reflux - GER

Gastroesophageal
Reflux Disease - GERD
(Symptomatic)

Primary GERD :
motility problem
affecting lower
esphageal sphincter

Secondary GERD :
external factor causing
transient relaxation of
lower esophageal sphincter
(e.g. Food Allergy)

Gastroesophageal Reflux
Physiological Gastroesophageal Reflux
(GER)

is a symptom, not a disease.

refers to the involuntary retrograde

flow of gastric contents across the
lower esophageal sphincter (LES)
into the oesophagus.

present in the majority of infants

first year of life (common).

Gastroesophageal Reflux
By 12 months majority with symptoms
resolve (maturation of oesophageal
sphincter, upright posture, incr solids
in diet).
Complications : failure to thrive,
oesophagitis, pulmonary aspiration.

Gastroesophageal Reflux
Gastroesophageal Reflux Disease (GERD)
Definition

The upper gastrointestinal tract

diseases which causes by the
reflux of the gastro-duodenal
content to esophagus.
Divided

Erosive type

Non-erosive type

Gastroesophageal Reflux
Gastroesophageal Reflux Disease/GERD
Complication

Barretts esophagus (BE) is one of

the GERD complications
(metaplastic collumnar epithelial
replaces the normal esophageal
squamous epithelial).

Constipation ?

Constipation
Definition

Decrease in stool frequency

fewer than 3 stools per week and
incomplete passing stoll hard
stool.

hard,

or Decreased fluidity of Bowel

movements most stools are
pebble-like or scybalous.

Constipation
Mean stool frequency
*
Breastfed infants under age months:
2.9 stools / day.
*
Formula-fed infants under age 3
months: 2 stools / day.
*
Age 6 to 12 months: 1.8 stools per
day.
*
Age 1 to 3 years: 1.4 stools per day .
*
Age over 3 years: 1.0 stools per day
Ref. Baker, J. Pediatr Gastrol Nutr, 1999, 29:612.

Constipation
Etiology of constipation
Dietary
Functional
Medications
Structural defects
Metabolic / endocrine disorders
Acute febrile illness
Acute abdomen with palpable fecal

Constipation
Etiology of constipation
Dietary
- excessive cows milk
- transition form breast milk to
formula
or table food
- lack of fiber
- dehydration
Functional
- lack of privacy (eg. start of daycare
or school).

Constipation
Etiology of constipation
Medications
- opiates
- anticholinergics
- lead poisonings.
Structural defects
- intussusception
- volvulus
- anal fissure.

Constipation
Etiology of constipation
Metabolic/Endocrine disorders
- cystic fibrosis
- increases calcium
- decreased kalium
- uremia
- hypothyroidism.
Acute febrile illness
Acute abd. with palpable fecal
masses.

Constipation
Functional Constipation (Rome III)
Diagnostic Criteria
Functional Constipation ?????

Ileus ?

Ileus
Definition of Ileus
Hypomotility of the gastrointestinal tract
in the absence of mechanical bowel
obstruction.
Failure of intestinal peristalsis without
evidence of mechanical obstruction.

Ileus
Clinical manifestation

Abdominal distention

Emesis

Minimal pain, increases with

increasing distention.

Bowel sounds are minimal or absent.

Plain abdominal radiographs

demonstrate multiple air-fluid levels
throughout the abdomen.

Differentiated of Ileus, Pseudo Obstruction and Mechanical

Obstruction
Ileus

Pseudo Obstruction

Mechanical
Obstruction

Symptom Mild abdominal pain,

bloating, nausea,
vomiting, obstipation,
constipation.

Crampy abdominal
pain, constipation,
obstipation, nausea,
vomiting, anorexia.

Crampy abdominal
pain, constipation,
obstipation, nausea,
vomiting, anorexia.

Physical Silent abdomen,

Examina- distention, tympanic
tion

Borborygmi,
tympanic, peristaltic
waves, hypoactive or
hyperactive bowel
sounds, distention,
localized tenderness

Borborygmi,
peristaltic waves,
high-pitched bowel
sounds, rushes,
distention, localized
tenderness

Plain
Radiographs

Isolated large bowel

dilatation, diaphragm
elevated

Bow-shaped loops in
ladder pattern, paucity
of colonic gas distal to
lesion, diaphragm
mildly elevated, airfluid levels

Large and small bowel

dilatation, diaphragm
elevated

Abdominal radiograph shows ileus

Abdominal radiograph shows low

intestinal obstruction

Ileus
Etiology

Abdominal surgery

Infection (pneumonia, gastroenteritis,

peritonitis)

Metabolic abnormalities (hypokalemia, hypercalcemia, hypermagnesemia, acidosis)

Drugs (opiates and vincristine)

Antimotility drugs (loperamide).

Ileus
Treatment
Correction of the underlying abnormality
Nasogastric decompression
Prokinetic agents : metoclopramide.

Hirschsprungs Disease ?
(mechanical obstruction)

Congenital Aganglionic Megacolon

(Hirschsprungs Disease)
Abnormal
innervation of the
bowel, beginning
in the internal anal
sphincter and
extending
proximally to
involve a variable
length of gut.

Hirschsprungs
Disease

Hirschsprungs Disease

Healthy large
intestine. Nerve
cells are found
throughout the
large intestine

Short-segment HD.
Nerve cells are
missing from the
last segment of the
large intestine

Long-segment HD.
Nerve cells are
missing from most
or all of the large
intestine and
sometimes the last
part of the small
intestine

Hirschsprungs Disease
Clinical Manifestation
Delayed meconium (99% passed
within
48 hr of birth).
Failure to thrive, with hypoproteinemia
from a protein-losing enteropathy.
Dilatation of the proximal bowel and
abdominal distention.
A large fecal mass, the rectum is
usually empty of feces.
The stools consist of small pellets, be
ribbon-like, or have a fluid consistency.

Hirschsprungs Disease
Treatment
Operative intervention
Complication
- Ulcerative colitis
- Colonic rupture

Inflamatory Bowel Disease ?

(IBD)

Inflamatory Bowel Disease (IBD)

Inflamatory Bowel Disease (IBD)
- Ulcerative Colitis
- Crohn Disease

Inflamatory Bowel Disease (IBD)

Ulcerative Colitis
Idiopathic chronic inflamatory disoder
Usually begins in the rectum (ulecerative proctitis) and extends proximally for
variable distance.
Continuous inflammation confined to
the large intestine pancolitis
(characterized ).

Inflamatory Bowel Disease (IBD)

Distal colon is most severely affected,
and the rectum is involved.
Inflammation is limited primarily to the
mucosa and does not extend through
all layers.

Granular mucosa
with edema,
erythema and
rarefied vessels.

Ulcerative
Colitis

Hemorrhagic
mucosa with
mucosal edema.

Edematous
mucosa with
ulcerations,
stenosis and
absent peristaltic
movements.

Sumber : The Gastrolab Image Library (hhtp://www.gastrolab.net)

Inflamatory Bowel Disease (IBD)

Crohn disease (CD)
Account for the disorders that represent
the Inflamatory Bowel Disease.
Characterized by a chronic inflammatory process that may affect any
segment of the gastrointestinal tract,
from mouth to anus, in a discontinuous
fashion.

Inflamatory Bowel Disease (IBD)

Crohn disease (CD)
Inflammatory process usually extends
through all layers of the intestinal wall.
Associated with remissions and
relapses and often recurs following
surgery.

LIPS

TONGUE

Crohns
disease can
affect the
gastrointestinal
channel from
the lips to the
anus

ORAL CAVITY

STOMACH

ESOPHAGUS

DUODENUM

ILEUM

ILEUM TERMINAL

VALVULA BAUHINI

ASCENDING COLON

CAECUM

Crohns disease, as described by Crohn, Ginzburg

and Oppenheimer in 1931, was a disease confined to
the distal part of the small bowel, and hence called
"regional ileitis" or "terminal ileitis".

Crohn's Disease Illustration

Inflamatory Bowel Disease (IBD)

Causes of Inflamatory Bowel Disease
Inflammation in IBD involves a complex
interaction of several factors:
* genes
* environment
* immune system.
Foreign substances (antigens) in the environment
may be the direct cause of the inflammation or they
may stimulate the body's defenses to produce
inflammation that continues without control .

Gastroenteritis ?
(Diarrhea)

Diarrhea
To increase in the frequency of bowel

movements or a decrease in the form

of stool (greater looseness of stool).
This condition of having three or more
loose or liquid bowel movement per
day.
when stools are softer and more
frequent then normal,usually more than
three bowel movements each day.

Diarrhea
To be distinguised

Incontinence of stool

Rectal urgency

Incomplete evacuation

Bowel movements immediately

after eating a meal.

Diarrhea
Diarrhea
* Acute diarrhea
* Chronic diarrhea
Acute diarrhea
an episode that has an acute onset and
lasts no longer than 14 days.
Chronic or persistent diarrhea
an episode that lasts longer than 14
days.

Diarrhea
Mechanism of diarrhea
* osmotic diarrhea
* secretory diarrhea

Diarrhea
Causes of Diarrhea

Bacterial infections

Viral infections

Parasite infections

Food intolerances

Reaction to medicine (drug)

Intestinal diseases

Functional bowel disorders

Assesment of dehydration
Moderate
dehydration
5-10%

Severe dehydration

General
appearance

Thirsty, drowsy

Drowsy, limp, cold, sweaty,

cyanotic extremities

Respiration*

Deep, may be rapid

Deep and rapid

Eyes

Sunken

Grossly sunken

Tears

Reduced/ absent

Absent

Mucous
membranes
Cap refill time*

Dry

Very dry

> 2 seconds

> 2 seconds

Tissue turgor*

Retracts slowly

Retracts very slowly

Radial pulse

Rapid and weak

Rapid, thready, may be

impalpable

Anterior fontanelle

Sunken

Very sunken

Urine output

Reduced

Marked oliguria

Body weight loss

>10%

Diarrhea

Reduced skin turgor in severe dehydration

Levels of dehydration (GastroHepatologi IDAI,2009)

CATAGORY

SIGN & SYMPTOM

Severe dehydration

Two or more signs or symptoms :

Lethargy, depressed consciousness
deeply sunken eyes (and/or fontanel
in a baby)
extreme thirst
recoil on skin turgor test in more than
2 seconds

Mild moderate
dehydration

Two or more signs or symptoms

Irritability
slightly sunken eyes (and/or fontanel
in a baby)
thirst
recoil on skin turgor test < 2 seconds

Non dehydration

No signs or symptoms of dehydration

Pediatrics GI Tract Bleeding ?

Gastrointestinal Tract Bleeding

Fairly common problem.
Differentiates upper vs. lower GI Tract
bleeding.
Upper GITract bleeding hematemesis
and melena
Hematemesis
- bright red or coffee ground color
Melena
- black, blood tarry stools; digested
blood
Site of bleeding :proximal to
ligament of
Treitz

Gastrointestinal Tract Bleeding

Lower Gastrointestinal Tract bleeding
hematochezia
Hematochezia
- bright red bleeding per rectum
- site of bleeding is usually
anorectal area

Differential Diagnosis of GI Tract Bleeding

New Born

Pre - School Age

School Age

Stress gastritis
Haemorrhagic
disease

Juvenile polyps
Infectious colitis

Juvenile polyps
Inflammatory bowel
disease

Swallowed
Maternal maternal
(APT tes)

Anal fissures

Anal fissures

Allergic/infectious
colitis

Foreign body

Hemorrhoids

Anal fissures

Vascular lesions

Drug ingestion

Intussusception,
volvulus

Henoch-Scholein
purpura, HUS

Infectious Diseases

Meckel's
Diverticulum

Infectious Disease

Haemorrhagic
disease

Abdominal Pain ?

Abdominal Pain
Chronic or recurrent abdominal pain.
Very common 10 15% of children
Duration longer than 3 months,
affecting
normal activity.
Range of anatomic, infectious,
inflammatory, biochemical disorders
Presents in 3 main patterns.
- Isolated paroxysmal abdominal pain
- Abdominal pain with dyspepsia.
- Abdominal pain with altered bowel
pattern.

Abdominal Pain
Causes of Recurrent Abdominal Pain
Common
Parasites
Faecal loading
Functional abdominal pain (Rome
III)
Less common
Infections
Inflammatory disorders
Renal cause

Abdominal Pain
Dyspepsia in children
Not as common as in adults
Relationship to eating not voluntered
Character of abdominal pain different
Causes
- Oesophagitis
- Ulcer dyspepsia
- Non-ulcer dyspepsia

Abdominal Pain
Dyspepsia in children (2)

Abdominal pain localized to the

epigastrium, right or left upper
quadrants, and episodic vomiting are
characteristic features of dyspepsia

Temporal relationship between meal

ingestion and the symptoms.

Presence of anorexia, nausea, oral

regurgitation, early satiety, postprandial abdominal bloating,
indigestion, and belching.

Abdominal pain
Red Flags in Pediatric Abdominal Pain
Persistent right upper or
right lower quadrant
pain
Pain that wakes the
child from sleep
Dysphagia
Arthritis
Persistent vomiting
Perirectal disease
Gastrointestinal blood
loss

Involuntary weight loss

Nocturnal diarrhea
Deceleration of linear
growth
Family history of
inflammatory bowel
disease, celiac disease,
or peptic ulcer disease
Delayed puberty
Unexplained fever

Drossman D, Corazziari E, Spiller R, Talley N, Thompson W, Whitehead W, eds. Rome III.

The Functional Gastrointestinal Disorders. 3rd ed. McLean, VA 2006

Childhood Functional
Gastrointestinal Disoders
Rome III ?

Functional Gastrointestinal Disoders (Rome III)

G. Functional disoders : neonates and todders
G1. Infant regurgitation
G2. Infant rumination syndrome
G3. Cyclic vomiting syndrome
G4. Infant colic
G5. Functional diarrhea
G6. Infant dyschezia
G6. Functional constipation

Functional Gastrointestinal Disoders (Rome III)

H. Functional disoders : children and adolescents
H1. Vomiting and aerophagia
H1a. Adolescent rumination syndrome.
H1b. Cyclic vomiting syndrome
H1c. Aerophagia
H2. Abdominal pain related FGIDs
H2a. Functional dyspepsia
H2b. Irritable bowel syndrome
H2c. Abdominal migraine
H2d. Childhood functional abdominal pain
H2d1. Childhoood functional
abdominal pain syndrome.

Functional Gastrointestinal Disoders (Rome III)

H. Functional disoders : children and adolescents (2)
H3. Constipation and incontinence
H3a. Functional constipation
H3b. Nonretentive fecal incontinence

References :
1. Talley NJ et.al. Consensus Asia-Pacific for dyspepsia.Journal
Gastroentero Hepatology, 1998;13; 335 - 53.
2. Drossman DA : Rome III; The New Criteria. Chinese Journal of
Digestive Diseases 2006; 7; 181 185.
3. Wyllie R. The digestive system. In: Kliegman RM, Behrman RE,
Jenson HB, Stanton BF. Nelsons Texbook of Pediatrics, 18 th,
Ed. Philadelphia: WB Saunders Co. 2007 ; 152 645.
4.

Sondheimer JM, Sundaram S. Gastrointestinal tract. In:Hay WW,

Levin MJ, Sondheimer JM, Deterding RR. Current Diagnosis &
Pediatrics, 19 th. Ed. New York: The Mcgraw-Hill W, 2009;577608.
Buku Ajar Gastroentero hepatologi, Ikatan Dokter Anak
Indonesia, edisi 1, Balai Penerbit FKUI, Jakarta. 2010.
5.

G. Childhood Functional GI Disorders: Infant/Toddler

G1. Infant Regurgitation

Diagnostic criteria Must include both of the following
in otherwise healthy infants 3 weeks to 12 months of
age:
Regurgitation two or more times per day for
or more weeks
No retching, hematemesis, aspiration, apnea,
failure to thrive, feeding or swallowing
difficulties, or abnormal posturing.

G. Childhood Functional GI Disorders: Infant/Toddler

G2. Infant Rumination Syndrome

Diagnostic criteria Must include all of the following for
at least 3 months:
Repetitive contractions of the abdominal
muscles, diaphragm, and tongue
Regurgitation of gastric content into the mouth,
which is either expectorated or rechewed and
reswallowed
AND ..

G. Childhood Functional GI Disorders: Infant/Toddler

G2. Infant Rumination Syndrome

. AND
Three or more of the following:
a. Onset between and months
b. Does not respond to management for
gastroesophageal reflux disease,or to anticholinergic drugs, hand restraints, formula
changes, and gavage or gastrostomy
feedings.
c. Unaccompanied by signs of nausea or
distress
d. Does not occur during sleep and when the
infant is interacting with individuals in the
environment.

G. Childhood Functional GI Disorders: Infant/Toddler

G3. Cyclic Vomiting Syndrome

Diagnostic criteria Must include both of the following:
Two or more periods of intense nausea and
unremitting vomiting or retching lasting hours
to days.
Return to usual state of health lasting weeks to
months.

G. Childhood Functional GI Disorders: Infant/Toddler

G4. Infant Colic

Diagnostic criteria Must include all of the following in
infants from birth to 4 months of age:
Paroxysms of irritability, fussing or crying that
starts and stops without obvious cause.
Episodes lasting or more hours/day and
occurring at least days/wk for at least
week.
No failure to thrive

G. Childhood Functional GI Disorders: Infant/Toddler

G7. Functional Constipation

Diagnostic criteria Must include one month of at least
two of the following in infants up to 4 years of age:
Two or fewer defecations per week
At least one episode/week of incontinence
after the acquisition of toileting skills
History of excessive stool retention
History of painful or hard bowel movements
Presence of a large fecal mass in the rectum
History of large diameter stools which may
obstruct the toilet.
Accompanying symptoms may include irritability, decreased appetite,
and/or early satiety. The accompanying symptoms disappear
immediately following passage of a large stool .