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ENCOPRESIS

Jay Fong, MD William T. Garrison, PhD

BASICS

DESCRIPTION

Voluntary or involuntary fecal soilage in a (typically) previously toilet-trained child

–Age may be chronologic or developmental.

–No underlying organic disease

–At least one event per month for 3 months

–Classified into functional constipation (retentive encopresis) and functional nonretentive fecal incontinence (FNRFI); both cause fecal incontinence. There is no constipation in FNRFI. Functional constipation is more

common.

System(s) affected: GI; psychological

Synonyms(s): fecal incontinence, soiling

EPIDEMIOLOGY

Incidence

Predominant sex: male > female (4 to 6:1) Constipation accounts for 3% of general pediatric referrals; up to 84% of constipated children have fecal incontinence at some point.

Prevalence

Occurs in 1–3% of children 4 years of age

ETIOLOGYAND PATHOPHYSIOLOGY

In 90% of cases, encopresis develops as a consequence of chronic constipation, with resulting overflow incontinence (retentive encopresis). The other 10% are caused by specific organic etiologies.

Chronic constipation with irregular and incomplete evacuation results in progressive rectal distension and stretching of the internal/external anal sphincters.

As a child habituates to chronic rectal distension, they may no longer sense the normal urge to defecate. Eventually, soft or liquid stool leaks around the

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retained fecal mass.

Many children voluntarily withhold stool in response to the urge to defecate for fear of pain or a preoccupation with not interrupting social activities. Psychological

–Stool withholding, fear, anxiety

–Difficulty with toilet training, including unusual anxiety or conflict with parent

–Resistance to using public toilet facilities, such as school bathrooms or outdoor toilets

–Known association with sexual abuse in boys; likely similar association in girls

–Developmental delay

Anatomic

–Rectal distension and desensitization

–Anal fissure or painful defecation

–Muscle hypotonia

–Slow intestinal motility

–Hirschsprung disease

–Cystic fibrosis

–Spinal cord defects (e.g., spina bifida)

–Congenital anorectal malformations

–Anal stenosis

–Anterior displacement of the anus

–Postoperative stricture of anus or rectum

–Pelvic mass

–Neurofibromatosis

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

Genetics

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None known; although incidence may be higher in children with family history of constipation

RISK FACTORS

Male gender

Constipation

Very low birth weight

Painful defecation

Difficulty with bowel training, including social pressure related to early daycare placement

Organic/anatomic causes

Anxiety and depression

Insufficient fluid or fiber intake

Refusal to use public restrooms

Attention deficit

History of abuse

GENERALPREVENTION

Family education: toilet training when ready; optimize fluid and fiber intake.

COMMONLYASSOCIATED CONDITIONS

Constipation, Hirschsprung disease

Cerebral palsy, cystic fibrosis

Developmental and behavioral diagnoses, urinary incontinence

DIAGNOSIS

HISTORY

Signs/symptoms of constipation:

–Hard, large-caliber stools

–<3 defecations per week

–Pain or discomfort with stool passage

–Withholding stool

–Blood on stool or in diaper/toilet bowl

–Decreased appetite

–Abdominal pain that improves with stool passage

–Hiding while defecating before child is toilet-trained; avoiding use of the

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toilet

–Diet low in fiber or fluids, high in dairy products

–No stool passage in the first 48 hours of life

–Pasty stool on underclothes

–Recurrent UTIs

Abrupt onset after age 5 years more likely to be associated with psychological trauma

Overlap with attention deficit disorder (ADD) common in children >5 years

Medication use: opiates, phenobarbital, and tricyclic antidepressants (TCAs)

Family history of constipation

PHYSICALEXAM

Neurologic exam of lower extremities and perineal area, with attention to S1– S4 distribution, perineal sensation, cremasteric reflex, and anal sphincter tone

Genital examination and digital rectal exam: Assess for anal fissures, sphincter tone, rectal distension/impaction, occult or visible blood.

Abdominal exam: bowel sounds, percussion note (tympany), abdominal distension; palpate for stool (most common in left lower quadrant).

DIAGNOSTIC TESTS & INTERPRETATION

Most cases diagnosed by history and physical

Initial Tests (lab, imaging)

Only to rule out organic causes

UA/urine culture: UTI/glucosuria

Thyroid function tests: hypothyroidism

Electrolyte panel, including calcium: hypokalemia, hypercalcemia, or hyperglycemia

Abdominal plain films if impaction is suspected and not detected by abdominal or rectal exam

Follow-Up Tests & Special Considerations

Failure to pass meconium within 48 hours of birth, failure to thrive, bloody diarrhea, or bilious vomiting in a neonate should be promptly evaluated to exclude aganglionic megacolon.

Constipation and diarrhea, rash, failure to thrive, or recurrent pneumonia should prompt evaluation for cystic fibrosis. Patients with abdominal distension or ileus should be evaluated for possible obstruction.

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Diagnostic Procedures/Other

Manometric studies may be useful in patients who have constipation that does not respond to treatment.

TREATMENT

GENERALMEASURES

Anticipatory toilet training advice about when children should reduce reliance on diapers or use pull-ups during the daytime hours (average age for toilet training in girls is 29 months; 31 months for boys)

Eliminate impaction prior to maintenance therapy.

Avoid frequent and repeated rectal exams, enemas, and suppositories, especially in infants.

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. Incorporate positive reinforcement for successful bowel movements.

MEDICATION

Remove impaction and start maintenance treatment.

No randomized, controlled studies have compared methods of disimpaction: can use oral agents, enemas, and rectal suppositories; oral agents are least traumatic. Glycerin suppositories are best option for infants.

First Line

Disimpaction with polyethylene glycol (PEG)

–Give 17 g (240 mL) water or juice: 1.0 to 1.5 g/kg/day for 3 days for disimpaction

–0.4 to 0.8 g/kg/day for maintenance

Disimpaction with mineral oil for child >1 year; give 15 to 30 mL/year of age to max 240 mL.

–Maintenance: 1 to 3 mL/kg/day or divided BID

–May mix with orange juice to make palatable; avoid in infants to avoid

aspiration pneumonia.

Other maintenance regimens include the following:

–Milk of magnesia (MOM) 400 mg (5 mL): 1 to 2 mL/kg/day BID

–Lactulose 10 g (15 mL): 1 to 3 mL/kg/day divided BID

–Senna syrup 8.8 g sennoside (5 mL): age 2 to 6 years: 2.5 to 7.5 mL/day

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divided BID; age 6 to 12 years: 5 to 15 mL/day divided BID

– Bisacodyl suppository 10 mg: 0.5 to 1 suppository once or twice per day

ISSUES FOR REFERRAL

If symptoms do not improve after 6 months of compliance with a multifactorial treatment model, refer to pediatric gastroenterologist for further evaluation and guidance.

ADDITIONALTHERAPIES

Behavioral treatment and counseling

SURGERY/OTHER PROCEDURES

If ongoing constipation is refractory to a combination of medical and behavioral therapy, consider anorectal manometry to evaluate for internal anal sphincter achalasia (or ultrashort-segment Hirschsprung disease). If present, this condition can be treated successfully in most patients with an internal sphincter myectomy.

COMPLEMENTARY& ALTERNATIVE MEDICINE

Children with volitional stool holding who receive behavioral treatment in addition to medications are more likely to have resolution of encopresis at 3 and 6 months than with medication alone (1)[A].

No evidence that biofeedback training adds benefit to conventional treatment for functional fecal incontinence in children (2)[A]

Behavioral interventions combined with laxative therapy (rather than laxative therapy alone) improve continence in children with functional fecal incontinence associated with constipation (1)[B].

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Admission criteria/initial stabilization

–Continued soiling and recurrent impaction on outpatient medical therapy, whether from lack of medication efficacy or patient nonadherence

–Decreased intake leading to malnutrition or dehydration

–Recalcitrant vomiting or concern for obstruction

–Involve appropriate agencies if concern for abuse.

–Hospital admission and abdominal films may be necessary to ensure

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complete removal of impaction. This may include direct gastric administration of balanced electrolyte–PEG solutions if the patient cannot tolerate by mouth. Serial abdominal films and observation of rectal effluent can help determine treatment adequacy.

IV fluids if the patient is dehydrated and has difficulty tolerating oral intake

Nursing to document stool output and character Discharge criteria

–Stools that are looser in consistency and clearer in appearance are a successful inpatient end point.

–Abdominal radiographs showing less fecal loading (compared with a pretreatment radiograph) with improving serial abdominal exams

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Continue maintenance treatment for 6 months to 2 years with visits every 4 to 10 weeks for support and to ensure compliance; more frequent visits with oppositional or anxious children

Telephone or virtual visits can be used to adjust doses and to provide ongoing encouragement.

Treat recurrences of impaction promptly.

Emphasize compliance with medication and self-initiation of regular bathroom visits.

Children who do not progress using a well-designed behavior plan should be referred for more in-depth mental health evaluation and counseling.

DIET

Adequate fluid and fiber intake (2)[A]. Reduce cow’s milk products. Avoid excessive consumption of bananas, rice, apples, and gelatin.

PATIENT EDUCATION

Demystify defecation.

Carefully explain the treatment plan including medications and dietary changes.

Avoid punishment for inadvertent soiling.

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In children >4 years of age, explain to parents how overreliance on diapers and pull-ups (while convenient) can prolong the problem.

Always attempt to use positive reinforcement for successful toilet sits and medication compliance.

If positive approach is unsuccessful, consider removing desired privileges (e.g., TV, video games) for noncompliance with behavioral plan. Some children respond well to a token economy (earned privileges) to promote desired behavior.

PROGNOSIS

Many children exhibit a good response and relapse due to parental noncompliance.

From 30% to 50% of children may still have encopresis after 5 years of treatment.

Children with psychosocial or emotional problems preceding the encopresis are more recalcitrant to treatment.

COMPLICATIONS

Colitis due to excessive enema/suppository

Perianal dermatitis

Anal fissure

REFERENCES

1.Brazzelli M, Griffiths PV, Cody JD, et al. Behavioural and cognitive interventions with or without other treatments for the management of faecal incontinence in children. Cochrane Database Syst Rev. 2011;(12):CD002240.

2.Tabbers MM, DiLorenzo C, Berger MY, et al; for European Society for Pediatric Gastroenterology, Hepatology, and Nutrition, North American Society for Pediatric Gastroenterology. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258–274.

ADDITIONALREADING

Constipation Guideline Committee of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Evaluation and treatment of constipation in infants and children: recommendations of the

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North American Society for Pediatric Gastroenterology, Hepatology and

Nutrition. J Pediatr Gastroenterol Nutr. 2006;43(3):e1–e13.

Levitt M, Peña A. Update on pediatric faecal incontinence. Eur J Pediatr Surg. 2009;19(1):1–9.

CODES

ICD10

R15.9 Full incontinence of feces

R15.1 Fecal smearing

F98.1 Encopresis not due to a substance or known physiol condition

CLINICALPEARLS

90% of encopresis results from chronic constipation.

Address toddler constipation early by decreasing excessive milk intake, increasing fruits/vegetables intake, and ensuring adequate fluid and fiber intake.

Eliminate fecal impaction before initiating maintenance therapy.

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ENDOCARDITIS, INFECTIVE

Lyudmila Burina Ganatra, DO, MS Theodore B. Flaum, DO, FACOFP

BASICS

DESCRIPTION

An infection of the valvular (primarily) and/or mural (rarely) endocardium

System(s) affected: cardiovascular, endocrine/metabolic, hematologic/lymphatic, immunologic, pulmonary, renal/urologic, skin/exocrine, neurologic

Synonym(s): bacterial endocarditis; subacute bacterial endocarditis (SBE); acute bacterial endocarditis (ABE)

EPIDEMIOLOGY

Incidence

Incidence rose in the United States between 2000 and 2011 from 11 per 100,000 to 15 per 100,000

1.5–3% incidence 1 year after prosthetic valve replacement; 3–6% 5 years postreplacement

Increasing incidence of cardiovascular device-related infections due to higher frequency of implantable devices, especially in the elderly

ETIOLOGYAND PATHOPHYSIOLOGY

ABE: Staphylococcus aureus; Streptococcus groups A, B, C, G; Streptococcus pneumoniae; Staphylococcus lugdunensis; Enterococcus spp. (gram-positive); Haemophilus influenzae or parainfluenzae; Neisseria gonorrhoeae (gramnegative)

SBE: α-hemolytic streptococci (viridans group strep), Streptococcus bovis,

Enterococcus spp., S. aureus, Staphylococcus epidermidis (gram-positive); HACEK organisms: Haemophilus aphrophilus or paraphrophilus, Actinobacillus (Aggregatibacter) actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae

Endocarditis in IV drug abusers (tricuspid valve): S. aureus, Enterococcus spp. (gram-positive); Pseudomonas aeruginosa, Burkholderia cepacia, other

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