CC: Abdominal pain, Vomiting, Constipation

• Differential

• Key History

  

• Key Physical Exam

  

• Initial Workup

  

• Workup: CBC, urinalysis, imaging as needed

• Surgical consult for suspected appendicitis

Gastroenteritis/Dehydration

• Primary assessment: Hydration status, mental status, perfusion

  • See dehydration section in renal:

    Renal

• Management: Oral/IV fluid rehydration, calculate fluid deficit

• Consider: Stool studies in severe cases

• Regular electrolyte monitoring

• Antiemetics if needed

  • The pediatric dose of ondansetron is 0.15 mg/kg per dose

Constipation

• History
  • symptoms, relief with BM?, diet, any associations noticed? weight loss, prior treatments, family history
• Differential Diagnosis
  • functional constipation, outlet dysfunction constipation, and slow transit constipation.
    • Functional constipation most commonly presents as decreased frequency or altered consistency of bowel movements resulting from very efficient colonic water absorption mechanism (hard/firm/painful bowel movements), delay in colonic transit time related to variation in motor activity or increased length of colon (decreased frequency), or variation in compliance of rectum affecting signaling to defecate (hard/firm consistency or decreased frequency).    Dietary factors, hydration, altered colonic bacterial flora (excessive methane production), specific medical conditions (hypokalemia, hypercalcemia, celiac disease, hypothyroidism, lead intoxication, milk protein allergy, spinal cord disorders, connective tissue disorder, generalized autonomic dysfunction, cystic fibrosis), complications from certain medications may trigger or aggravate functional constipation.
    • Outlet dysfunction constipation may be primary (Hirschsprung's, achalasia, neuropathy affect signaling to defecate) or secondary to chronic fecal retention.  Most cases of outlet dysfunction constipation result from chronic fecal retention.  Chronic fecal retention can be behavioral (voluntary withholding triggered by functional constipation), situational (eg toilet phobia, ADD, too busy playing, fear of using bathrooms outside the home), secondary to abnormal defecation dynamics (failure to relax external anal sphincter or pelvic floor muscles during attempted defecation), or secondary to altered consciousness rectal sensitivity threshold (signaling of need to defecate, signaling that defecation is complete) from acquired megarectum.  Rarely, patients may have a primary neuropathy resulting in increased conscious rectal sensitivity threshold in which they do not experience the correct signals to defecate.
    • Slow transit constipation is the disorder of colonic motility in which either a neuropathy or myopathy results in colonic inertia.  Extensive megacolon or dilated colon from gaseous distention may also trigger slow transit constipation.
    • Potential confounding variables include hyperflexibility (Ehlers-Danlos syndrome), generalized autonomic dysfunction
• Treatment
  • Chronic constipation
    • scheduled toilet sits, 8 minutes, 20 minutes after meals
    • Squat a potty
    • optimize hydration
    • food that can make you go: apples, pears, kiwi, apricots, papaya, aloe
    • next lab draw (UCSF) : recheck ESR, CRP TSH and free T4
    • stool studies (UCSF): calprotectin
    • Sitz marker test in the future when on maximum stimulant therapies (will mail to you anyways now because takes long time to get there and sometimes gets lost in the mail)
    • Referral to Stanford for anorectal manometry testing
  • Maintenance Regimen
    • The goal of maintenance regimen is to keep you empty and prevent from needing a clean out. There will be a trial-error stage in which we try to find the perfect regimen.
    • Osmotic laxatives draws the water into the stool and makes it soft. We attain SOFT consistency stool with this medication -> Miralax 2 cap daily
    • Stimulant laxatives helps contract the colon and rectum to push the stool out. We attain daily large volume stools with this medication -> Increase ex lax to 2 tabs daily. Look out for urge to stool and spontaneous bowel movements WITHOUT the peristeen. If not, will increase to 3 tabs in a week and then Will increase 4 tabs after that.
    • Peristeen enema - continue daily until spontaneous bowel movements increase.