Constipacin en

Pediatra
(Constipacin
funcional).
David Esteban Estrada V.
X Semestre.
Programa Medicina.
Universidad de Nario.
San Juan de Pasto.
04 de marzo de 2015.

Introduccin.

Constipacin en Pediatra.
Introduccin.
Deposicin: menor a 3/Semana. + Sntomas
asociados. + Retencin de Heces. +
Escurrimiento.
Coran A, Pediatric surgery, Seventh edition vol 1, Ed. Elsevier, 2012.

Evac. Inal.
Infrecuente.

Heces
Pequeas
y duras.

Evacuaci
n dolorosa
(Heces de
gran
dimetro.

Incontinencia
Fecal
(Encopresis).

Sood M, Constipation in children: Etiology and diagnosis, UpToDate, 2014.

Rubin GP, Childhood constipation, Am Fam Physician. 2003.

Constipacin en Pediatra.
Introduccin.
Definiciones.

Constipacin.
Constipacin.

Impactacin
Impactacin
fecal.
fecal.

Carreo W, et al,
Estreimiento crnico,
Programa de educacin
continua en pediatra
(PRECOP- SCP). Vol. 9, 1: 2543. 2011.

Encopresis
Encopresis
..

Incontinencia
Incontinencia
fecal.
fecal.

Constipacin en Pediatra.
Epidemiologa.
Constipacin.
Comn entre nios (3 a 5% consultas
peditricas).
Prevalencia (1 30%), es mayor en aos
pre escolares.
No varia por genero./ Nivel
Socioeconmico.
Sood M, Constipation in children: Etiology and
diagnosis, UpToDate, 2014.
Van den Berg MM, Benninga MA, Di Lorenzo C,
Epidemiology of childhood constipation: a systematic
review, Am J Gastroenterol. 2006.

Constipacin en Pediatra.
Epidemiologa.
3 al 5% de las consultas
ambulatorias peditricas.
15 al 25% de las consultas
especializadas en
gastroenterologa peditrica.

IPS
IPS Gastronutriped
Gastronutriped :: atendi
atendi a
a
287
287 pacientes
pacientes con
con diagnstico
diagnstico
de
de estreimiento
estreimiento (27%)
(27%) sobre
sobre
un
un total
total de
de 1.102
1.102 consultas
consultas
entre
entre el
el ao
ao 2007
2007 a
a 2008.
2008.
El 51% de los casos con dolor
abdominal
abdominal recurrente
recurrente
presentaban
presentaban estreimiento.
estreimiento.

Prevalencia: 0,3 28%.

Pequeo predominio por

genero masculino.

Carreo W, et al, Estreimiento

crnico, Programa de educacin
continua en pediatra (PRECOP- SCP).
Vol. 9, 1: 25-43. 2011.

Constipacin en Pediatra.
Patrones de deposiciones
normales.
Constipation is generally understood as difficulty
or reduced frequency in defecation.

The frequency and type of stools must be

interpreted in the context of the child's age, diet,
and stage of maturation.

Di Lorenzo C, Pediatric anorectal disorders, Gastroenterol Clin

North Am. 2001

Frecuencia de
defecacin.

Recin Nacido.

Meconio (90%) Primeras

24h; generalmente
primeras 36h.

Primera semana de vida.

Cuatro deposiciones por

dia.

Tres primeros meses.

Lactancia: 3/da.
Frmula: 2/da.

Dos aos.

2/da.

Cuatro aos.

1/da.

Edad.
Trnsito G.I.
Volumen
crtico:
en
Volumen
crtico: Cantidad
Cantidad expresada
expresada
en cc
cc o
o ml
ml de
de
materia
fecal
recto,
estimula
materia
fecal que
que distiende
distiende el
el8,5
recto,
estimula los
los
1 a 3 meses.
horas.
receptores
receptores de
de la
la ampolla
ampolla rectal,
rectal, desencadenado
desencadenado la
la
4
a
24
meses.
16
horas.
urgencia
urgencia de
de defecacin.
defecacin. (VCN:
(VCN: 15cc).
15cc).
Carreo
W,
Programa
3 a 13 aos.
26 horas.
Carreo
W, et
et al,
al, Estreimiento
Estreimiento crnico,
crnico,
Programa de
de educacin
educacin
continua
en
Vol. 9,
continua
en pediatra
pediatra (PRECOP(PRECOP- SCP).
SCP).
9, 1:
1: 25-43.
25-43. 2011.
2011.
Pubertad.
30 a Vol.
48 horas.

Sood M, Constipation in children: Etiology and diagnosis,

UpToDate, 2014.
Van den Berg MM, Benninga MA, Di Lorenzo C, Epidemiology
of childhood constipation: a systematic review, Am J
Gastroenterol. 2006.

Patrones de deposiciones
normales.
Constipacin
en Pediatra.

Edad.

Condicin para evacuacin normal.

Constipacin en Pediatra.

Volumen
Volumen adecuado
adecuado de
de
materia
materia fecal.
fecal.
Funcionalidad
Funcionalidad motriz
motriz
del
del colon,
colon, recto
recto y
y
ano.
ano.
Reflejo
Reflejo anorectal
anorectal
adecuado.
adecuado.
Participacin
Participacin
voluntaria.
voluntaria.
Normalidad
Normalidad
anatmica
anatmica anorectal.
anorectal.

Carreo W, et al,
Estreimiento
crnico, Programa
de educacin
continua en
pediatra
(PRECOP- SCP).
Vol. 9, 1: 25-43.
2011.

Constipacin
Funcional.

Constipacin Funcional.

Infrecuencia en la
defecacin.

Defecacin dolorosa.
Incontinencia fecal 80%.
Dolor abdominal.

Distress para el nio y su familia.

Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional
constipation in infants and children: evidence-based recommendations from
ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014.
van den Berg MM, Benninga MA, Di Lorenzo C. Epidemiology of childhood
constipation: a systematic review. Am J Gastroenterol 2006.

Constipacin Funcional.
1. Definicin.

Criterios de Roma III.

Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional
constipation in infants and children: evidence-based recommendations from ESPGHAN
and NASPGHAN. J Pediatr Gastroenterol Nutr 2014.

Constipacin Funcional.
1. Definicin.

Criterios de Roma III.

Devanarayana NM, Adhikari C, Pannala W, et al. Prevalence offunctional

gastrointestinal diseases in a cohort of Sri Lankan adolescents: comparison between
Rome II and Rome III criteria. J Trop
Pediatr 2011.
Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional
constipation in infants and children: evidence-based recommendations from ESPGHAN
and NASPGHAN. J Pediatr Gastroenterol Nutr 2014.

Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and

treatment of functional constipation in infants and children:
evidence-based recommendations from ESPGHAN and
NASPGHAN. J Pediatr Gastroenterol Nutr 2014.

Constipacin Funcional.

Onset
Onset of
of symptoms
symptoms in
in infants
infants <1
<1 month
month old
old raises
raises the
the suspicion
suspicion of
of
the
the presence
presence of
of an
an organic
organic condition
condition such
such as
as Hirschsprung
Hirschsprung disease;
disease;
the
the failure
failure of
of passage
passage of
of meconium
meconium within
within the
the first
first 48
48 hours
hours of
of life,
life,

Constipacin Funcional.
Functional
Functional constipation
constipation describes
describes persistent
persistent
difficult,
difficult, infrequent,
infrequent, or
or seemingly
seemingly incomplete
incomplete
defecation,
defecation, without
without evidence
evidence of
of a
a primary
primary
anatomic
or
anatomic
or biochemical
biochemical
cause
Thompson
WG, Longstreth
GF, Drossmancause
DA, et al. Functional bowel disorders
and functional abdominal pain. Gut 1999.

Etiologa
.
Introduccin de
cereales y alimentos
slidos.

Control de
esfnteres.

Di Lorenzo C, Pediatric
anorectal disorders,
Gastroenterol Clin
North Am. 2001

Inicio de la
escuela.

Autism
Autism spectrum
spectrum disorders
disorders (ASD)
(ASD) appear
appear to
to predispose
predispose to
to
functional
functional constipation
constipation with
with or
or without
without fecal
fecal incontinence.
incontinence.

Etiologa
.

Sood M, Constipation in children: Etiology and

diagnosis, UpToDate, 2014.

Partin JC, Hamill SK, Fischel

JE, Partin JS, Painful
defecation and fecal soiling in
children,
Pediatrics. 1992.

Defecacin dolorosa.

Constipacin Funcional.

Constipacin Funcional.
Etiologa
.
Problemas en control de esfnteres.
Para ir al bao.

Capacidad e inters en la
retencin de evacuacin
intestinal.
Sood M, Constipation in children: Etiology and
diagnosis, UpToDate, 2014.

El control de esfnteres es un hito del desarrollo

que afecta la autoestima y la independencia.

of
of functional
functional constipation
constipation in
in infants
infants and
and
A
randomized
sample
children:
evidence-based
A
randomized
sample of
of children
children (291
(291
children:
evidence-based
children
with
and
recommendations
from
and
children
with constipation
constipation
and 1602
1602
recommendations
from ESPGHAN
ESPGHAN
and
controls)
aged
2
years
controls)
aged
2 to
to 14
14 Gastroenterol
years was
was taken
taken
NASPGHAN.
JJ Pediatr
NASPGHAN.
Pediatr
Gastroenterol
from
three
of
from
of the
the 52
52 counties
counties of
of Greece.
Greece.
Nutr.
2014;58(2):258.
Nutr.three
2014;58(2):258.
Tabbers
MM,
Nonpharmacologic
Tabbers
MM,may
Nonpharmacologic
Lack
play
Lack of
of fiber
fiber
may
play an
an important
important role
role in
in
treatments
for
childhood
constipation:
treatments
forchronic
childhood
constipation:
the
idiopathic
the etiology
etiology of
of
chronic
idiopathic
systematic
2011;128(4):753.
constipation
in
systematic
review.
2011;128(4):753.
constipation review.
in children.
children.

Sood M, Constipation in
children: Etiology and
diagnosis, UpToDate, 2014.

Fibra.
Fibra.

Etiologa
.
Tabbers
MM,
and
Tabbers
MM, Evaluation
Evaluation
and treatment
treatment
Consideraciones
dietticas.

Productos
Productos Lcteos.
Lcteos.

Constipacin Funcional.

Roma E, Diet and chronic constipation in

children: the role of fiber. J Pediatr Gastroenterol
Nutr. 1999.

Unlike
Unlike previous
previous generations,
generations, children
children today
today consume
consume large
large
amounts
amounts of
of highly
highly processed
processed food
food items
items at
at the
the expense
expense of
of
fruit,
fruit, vegetables,
vegetables, and
and fiber
fiber

Carreo W, et al, Estreimiento

crnico, Programa de educacin
continua en pediatra (PRECOPSCP). Vol. 9, 1: 25-43. 2011.

Constipacin Funcional.
Clnica.

Constipacin Funcional.
3. Diagnstico.
Examen
Sensitivity
Rectal. of
77%,
Specificity of
35%, LR 1,2.

In
In conclusion,
conclusion, evidence
evidence does
does not
not support
support the
the use
use
of
of digital
digital
rectal
examination
to
diagnose
functional
rectal
functional
Tabbers
MM, examination
DiLorenzo C, Berger MY,to
et al.diagnose
Evaluation and treatment
of functional constipation in
infants
and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr
constipation
constipation
Gastroenterol Nutr 2014.
Sood M, Constipation in children: Etiology and diagnosis, UpToDate, 2014.

Constipacin Funcional.

3.2. Test
Diagnsticos.

Radiografa de Abdomen.

Barr
Barr RG,
RG, Levine
Levine MD,
MD, Wilkinson
Wilkinson RH,
RH, et
et al.
al. Chronic
Chronic and
and occult
occult
stool
stool
retention:
retention: a
a clinical
clinical tool
tool for
for its
its evaluation
evaluation in
in school-aged
school-aged
children.
children. Clin
Clin Pediatr
Pediatr (Phila)
(Phila) 1979:
1979: Sensibilidad
Sensibilidad de
de 80%
80% (95%
(95%
CI
CI 6590)
6590) y
y una
una especificidad
especificidad de
de un
un 90%
90% (90%
(90% CI
CI 7498).
7498).
Benninga
Benninga MA,
MA, Buler
Buler HA,
HA, Staalman
Staalman CR,
CR, et
et al.
al. Defaecation
Defaecation
disorders
disorders
in
in children,
children, colonic
colonic transit
transit time
time versus
versus the
the Barr-score.
Barr-score. Eur
Eur JJ
Pediatr
Pediatr
1995:
1995: sensibilidad
sensibilidad de
de un
un 60%
60% (95%
(95% IC
IC 4672)
4672) y
y una
una
They
the
evaluation
especificidad
de
un43%
(95%
1871).
They are
are not
not an
an
essential
part
ofIC
the
evaluation of
of constipation
constipation
especificidad
deessential
un43% part
(95%of
IC
1871).
and
and should
should not
not be
be used
used as
as a
a substitute
substitute for
for a
a thorough
thorough history
history
and
and physical
physical examination
examination
Sood M, Constipation in children: Etiology and diagnosis, UpToDate, 2014.

Constipacin Funcional.

3.2. Test
Diagnsticos.
Enema de Bario.
Evidencia de
apoyo para
E.H S :70%,
E:83%.

Radiografa Lumbosacra.
Manometra Anorectal.
Biopsia.
Transito
Intestinal.

Sood M, Constipation in children: Etiology and diagnosis, UpToDate, 2014.

Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional
constipation in infants and children: evidence-based recommendations from
ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr 2014.
Carreo W, et al, Estreimiento crnico, Programa de educacin continua en
pediatra (PRECOP- SCP). Vol. 9, 1: 25-43. 2011.

Constipacin Funcional.

Sood M, Constipation in children: Etiology and

diagnosis, UpToDate, 2014.

Constipacin Funcional.
Tratamiento.

Oral: PEG 0,3 a 1,4

g/kg/da.
Desimpactacin.

Carreo W, et al, Estreimiento

crnico, Programa de educacin
continua en pediatra (PRECOPSCP). Vol. 9, 1: 25-43. 2011.

Rectal: < 2 aos: SSN

0,9% dosis 5cc/kg/da por
das.
> aos: Enema
fosfatados: cc/kg/da.

Tratamiento.

Constipacin Funcional.

Hidrxido de
magnesio.

Carreo W, et al,
Estreimiento
crnico, Programa de
educacin continua
en pediatra (PRECOPSCP). Vol. 9, 1: 25-43.
2011.

< 2 aos:

0,5 cc/kg/da.

2 a 5 aos.

5 a 15 cc/da.

Lactulosa: Dosis es de 1 a 2 cc/kg/da.

6 a 12 aos.
15 a 30 cc/da.
Sorbitol: Dosis es de 1-3 cc/kg/da.
> 12 aos.
30 a 60 cc/da.
Polietilenglicol sin electrolitos: la dosis es de 0,8 a 1

Tratamiento.

Constipacin Funcional.

4. Irritantes o estimulantes: efecto teraputico se

Carreo W, et al, Estreimiento crnico, Programa de educacin continua en pediatra
logra
entre 6 y 8 horas: Aceite de ricino, Bisacodilo:
(PRECOP- SCP). Vol. 9, 1: 25-43. 2011.
Dosis 0,3 mg/kg/da con un mximo de 30 mg/da

Gracias.