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I struggled to find PEM resources for my CT3 year, despite the variety of excellent resources out there. I hope this website will help point you in the right direction. I'm not a PEM expert, but am following the guidance CEM have issued (in the form of a syllabus) to put together this page. This page is not endorsed by CEM, and any mistakes are mine.

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Tuesday, 2 June 2015

Constipation

Constipation is common. DFTB has written some excellent pieces of work on this - I've written myself more of a summary using their resources, and some I've found from elsewhere. 

Definitions
RomeIII Criteria: 
≤2 stools per week for a duration of 2 months if patient >2 years
                               for duration of 4 months if patient <2 years
or with evidence of overflow incontinence (no stool, then diarrhoea, then no stool, etc), 
or stools that clog toilet

Chronic: >8 weeks
Happens in 5 - 30%of the child population, progressing to chronic in > 1/3 of patients

<3 months, 2-3 stools/ day, 8.5 hours mouth to rectum time
<2 years, <2/ day, 16 hours mouth to rectum time

Reservoir Constipation
- Too busy to poo, scared to poo leads to reservoir constipation. Stools get larger and harder. Pass a large diameter stool every 1-2 weeks. It's painful to pass these.
The rectum stretches. The internal sphincter struggles leading to a numb, toneless rectum. Chronically, can lead to anal fissures, which are painful so poo-ing is avoided. The stool continues to become harder and more painful to pass.

Hirschprung's Disease
1/500 live births
Normally diagnosed in newborns. 
Get abdominal distension that is relieved by rectal stimulation, or enemas.

Cow's Milk: Tolerance may lead to constipation - should be investigated by a specialist before avoiding cow's milk. 

Examination
Weigh the child
Abdo exam
Perianal exam – appearance, position, patency, fissures
Scoliosis + Gait 
Skin overlying the spine – discoloured/sinus/hairy patch/central pit
Gluteal muscles – is there asymmetry?
Neuro
No PR

Red Flag Features
Constipation from early infancy
Delay in meconium >48hrs
Ribbon stools
Abdo distension & vomiting
Abnormal appearance of anus including multiple anal fissures
Asymmetry/flattening of gluteals
Sacral agenesis, skin changes over spine
Skin changes overlying spine
Deformity of lower limbs – talipes
Abnormal neuromuscular signs

Treatment
This is summarised so clearly on CYP that I haven't re-written it
- Get rid of old, dark, hard and smelly poo
- Continue treatment for 3 months. 
- Make going to the toilet fun




References

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