MOKGWANE EUTLWETSE SPARKS5TH YEAR MED STUDUWI, BAHAMAS CAMPUS

• DEFINITION• EPIDEMIOLOGY & DEMOGRAPHICS• ETIOLOGY• PHYSICAL FINDINGS & CLINICAL PRESENTATION• DIFFERENTIAL DIAGNOSIS• WORKUP• TREATMENT• PROGNOSIS• REFERRAL• PEARLS & CONSIDERATIONS• EVIDENCE-BASED REFERENCE• REFERENCE

Encopresis is the voluntary or involuntary passage of stool into inappropriate places, in children over the developmental age of 4 yr, with the absence of direct physiologic causes.

Occurs at least once per month for at least 3 months.

787.6 INCONTINENCE OF FECES

307.7 ENCOPRESIS

PEAK INCIDENCE: 4 to 5 yr of age PREVALANCE (IN U.S.): 1% to 1.5% of

children ages 5-8. PREDOMINANT SEX: Male > female

(ratio of 4:1) PREDOMINANT AGE: 4 to 9 yr of age GENETICS: Factors that contribute to

slow gut motility may predispose to encopresis

• Children with encopresis exhibit abnormal anorectal dynamics.

• Primary encopresis may be related to developmental delay of sphincter control.

• Secondary encopresis develops in the setting of constipation.

• Approximately 96% of children will have bowel movements between three times daily to once every other day.

When bowel movements are less frequent, stool becomes drier and harder and much more uncomfortable to pass.

Soiling results from more liquid stool that leaks around the main stool mass.

• Constipation may begin gradually as a result of a slow decrease in elimination frequency or more acutely after an illness, dehydration, or prolonged bed rest.

• In encopresis without constipation and overflow incontinence, soiling is often intentional. This may occur in the setting of oppositional-defiant disorder or conduct disorder

Harsh or inconsistent toilet training and resultant anxiety may lead to retention of stool, constipation, and eventually encopresis.

Most children attain fecal continence by the age of 4.

In Primary encopresis, continence is never fully established

Secondary encopresis incontinence is preceded by a year or more of continence.

In primary encopresis, stool is more likely to be normal in character.

Soiling is intermittent and usually in a prominent location.

Coexisting oppositional-defiant or conduct disorders are frequent.

• In secondary encopresis, constipation is generally severe.

• Causes an overflow incontinence in which soft or liquid stool flows around the retained feces, often several times per day.

• Defecation is usually uncomfortable or painful, so patient avoids defecation with consequent stool retention.

Stool is usually poorly formed and leakage is continuous (occurring during sleep and wakefulness).

Encopresis resolves when the constipation is resolved.

Hirschsprung's disease

Endocrine disease (hypothyroidism)

Cerebral palsy Myelomeningocele Pseudoobstruction Anorectal lesions

(rectal stenosis)

Malformations Trauma Rectal prolapse Medications

HISTORY:

Pay particular attention to frequency of elimination.

Character of the stool. Associated pain. Presence of enuresis (with which it is

frequently associated).

Evaluate child for other developmental or psychiatric problems.

PHYSICAL EXAMINATION: pay particular attention to the

abdomen, anus, rectum, and saddle sensation.

CONSIDER:

Thyroid function tests Electrolytes Calcium Urinalysis Culture

Abdominal imaging to determine extent of obstruction or megacolon (abdominal radiograph).

Anorectal manometric studies to determine sphincter function if Hirschsprung's disease is suspected;

If abnormal, follow up with a barium enema and rectal biopsy .

It is a test that evaluates bowel function in patients with constipation or stool leakage.

  It is done on an outpatient basis with mild discomfort.

The test measures the following parameters;

Strength of the anal sphincter muscles Sensation of stooling in the rectum Reflexes that govern bowel Movements of the rectal and anal

muscles

Indicated to rule out the following conditions;

Constipation, particularly difficulty with stool evacuation (dyssynergic defecation)

Stool leakage or fecal incontinence Hirshsprungs disease (a childhood disorder) Anorectal function before or after bowel

surgery

The test takes about 60 minutes.  A small, flexible sensor is placed in the

rectum. 

It is then connected to a computer and a recording device that measures the pressure and strength of the anal and rectal muscles. 

During the procedure, patient will be asked to perform certain maneuvers such as to squeeze, to relax or push as if to pass stool.

Small balloon attached may be inflated in the rectum to assess the normal reflexes and to assess the patient perceive stool sensation in the rectum.

Anorectal manometry is a safe test. It is unlikely to cause pain .

Rare complications include the following; possible perforation or bleeding of the

rectum. Allergic reaction to persons insensitive to

latex. Patients may feel shy or embarrassed

during the test.

NONPHARMACOLOGIC THERAPY;

Behavioral and/or individual psychotherapy and family therapy.

Biofeedback advocated by some to improve sphincter function.

• In secondary encopresis, disimpaction with isotonic saline enemas .

• Resistant cases: repeated instillation of 200 to 600 ml of milk of magnesia enemas .

• If child does not permit enemas: oral disimpaction with large doses of mineral oil or lactulose until stool mass is cleared (note: this is frequently more painful and more uncomfortable than an enema)

• Prevention of recurrence of constipation by increased dietary fiber, bulk agents and the use of laxatives (Senokot) and stool softeners (Colace).

• In primary encopresis, continue with nonpunitive toilet training and encourage regular toilet times (the latter is also helpful in secondary encopresis)

• A systematic review found some evidence that behavioral intervention plus laxative therapy, rather than behavioral therapy or laxative therapy alone, improves continence in children with primary and secondary encopresis. There was no evidence that biofeedback adds any benefit to conventional management of encopresis and constipation in children.

Brazelli M, Griffiths P: Behavioural and cognitive interventions with or without other treatments for defaecation disorders in children. Cochrane Database Syst Rev 2001;CD002240

In most cases encopresis is self-limited and of relatively brief duration.

If patient is resistant to treatment.

If complicated family factors are involved.

If encopresis is purposeful.

It is important to educate parents and children as to the nature of the problem and to defuse hostile or negative interactions between them.

Medscape American Academy of Pediatrics Ferri's Clinical Advisor 2008, 10th ed http://www.gastroconsultantsqc.com/

services/procedures/anorectal-manometry/