Billie is 6 years old. He has been experiencing abdominal pain and has been passing hard stools with difficulty. Last night he had some rectal bleeding.
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(a) What is his diagnosis?
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Billy is constipated and his rectal bleeding in all likelihood is due to an anal fissure. The diagnosis of constipation is made on the basis of infrequent hard stools passed with difficulty. It should not be made on infrequent bowel movements alone.
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(b) How would you treat him and how long for?
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Billy needs laxatives for a period to soften his stools and to allow the anal fissure to heal. The medication of choice is an iso-osmotic agent, polyethylene glycol (e.g. Movicol), although an osmotic laxative (lactulose) or a bowel stimulant is sometimes also used.
Dietary advice is important—eating high-fibre foods such as wholewheat products and vegetables will help resolve the problem and prevent recurrence. Fruit and orange juice helps to soften stools. It is important that Billy has a good fluid intake.
The duration of treatment depends on how long he has been suffering from constipation and laxatives may be required for some months. Parents are often concerned about dependence on laxatives but this is not a problem in childhood.
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(c) What would make you think of Hirschspung’s disease as a diagnosis?
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You should consider Hirschsprung’s if a child has delayed passage of meconium beyond the first 24 hours in the neonatal period, constipation from infancy and if there is significant weight faltering and poor growth.
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(d) What is the likely explanation?
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Billy’s soiling is no doubt due to overflow of liquid stool around constipated faeces. Good doses of laxative are required to clear the constipation; this can make the soiling worse in the short run.
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(e) What is the difference between soiling and encopresis?
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Soiling is defined as the involuntary passage of faeces and results from leakage of liquid stool around impacted faeces. Encopresis is the voluntary passage of stools in inappropriate places (including underwear) by a child who is mature enough to be continent. It is indicative of severe behaviour problems.
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(f) What is his prognosis?
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Billy's prognosis is good provided laxatives are taken on a regular basis for some months and his diet contains good amounts of fibre to prevent constipation developing again.