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.

Please comment with corrections, additions and further suggestions.

All the information here is collected from the internet, and it might be out of date or inaccurate, so please use your judgement and adhere to your hospital's protocols. If you do notice any errors or omissions please comment so we can put them right!

To navigate, decide whether you want to start with a PMP or a PAP. You can then select which PMP or PAP you want to look at. You will then be taken to the summary page for that PMP, with links expanded topic collections. If you know what topic you want to look at already, click on the link on the right hand side.

Tuesday, 2 June 2015


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. 

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. 

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?

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

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



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  3. Thanks for sharing these great information about Constipation. All the information highly professional words for educated peoples. After-all all info are more helpful for hemorrhoids or piles patients. I would also suggest to take piles supplements.