Органічні причини закрепів у немовлят і дітей

Cause

Suggestive Findings

Diagnostic Approach

Anatomic

Anal stenosis

Delayed passage of stool in the first 24–48 hours of life

Explosive and painful stools

Abdominal distention

Abnormal appearance or position of the anus

Tight anal canal detected by digital examination

Clinical evaluation

Anteriorly displaced anus

Severe chronic constipation with marked straining and pain when stool is passed

Typically no response to aggressive use of stool softeners and cathartics

Anal opening not located in the center of the pigmented area of the perineum

Calculation of anal position index* indicating anterior placement, which varies by sex:

  • Girls: < 0.29

  • Boys: < 0.49

Imperforate anus

Abdominal distention

No passage of stool

Abnormal appearance or position of the anus or possibly no anus

Clinical examination

Endocrine or metabolic disorders

Diabetes insipidus

Polydipsia

Polyuria

Excessive crying quieted with water intake

Weight loss

Vomiting

Urine and serum osmolality

Antidiuretic hormone levels

Serum sodium

Sometimes water deprivation test

Hypercalcemia

Nausea, vomiting

Muscle weakness

Abdominal pain

Anorexia, weight loss

Polydipsia

Polyuria

Serum calcium

Hypokalemia

Muscular weakness

Polyuria, dehydration

History of growth failure

Possibly history of aminoglycoside, diuretics, cisplatin, or amphotericin use

Electrolyte panel

Hypothyroidism

Poor feeding

Bradycardia

Large fontanelles and hypotonia in neonates

Cold intolerance, dry skin, fatigue, prolonged jaundice

Thyroid-stimulating hormone (TSH)

Thyroxine (T4)

Spinal cord defects

Myelomeningocele

Grossly visible lesion in vertebral spine at birth

Decrease in lower-extremity reflexes or muscular tone

Absence of anal wink

Plain x-rays of lumbosacral spine

Spinal MRI

Occult spina bifida

Possibly sacral hair tuft or pit

Spinal MRI

Tethered cord

Change in gait

Pain or weakness in lower extremities

Urinary incontinence

Back pain

Spinal MRI

Spinal cord tumor or infection

Back pain

Pain or weakness in lower extremities

Decrease in lower-extremity reflexes

Change in gait

Urinary incontinence

Spinal MRI

Intestinal disorders

Celiac disease (gluten enteropathy)

Symptom onset after introduction of wheat into diet (typically after age 4–6 months)

Failure to thrive

Recurrent abdominal pain

Bloating

Diarrhea or constipation

Complete blood count

Serologic screening for celiac disease (IgA antibody to tissue transglutaminase)

Endoscopy for duodenal biopsy

Cow's milk protein intolerance (milk protein allergy)

Vomiting

Diarrhea or constipation

Hematochezia

Anal fissures

Failure to thrive

Symptom resolution with elimination of cow's milk protein

Sometimes endoscopy or colonoscopy

Cystic fibrosis

Delayed passage of meconium or meconium ileus in the neonate

Possible repeated episodes of small-bowel obstruction (meconium ileus equivalent) in older children

Failure to thrive

Repeated episodes of pneumonia or wheezing

Sweat test

Genetic testing

Hirschsprung disease

Delayed passage of meconium

Abdominal distention

Tight anal canal detected by digital examination

Barium enema

Anorectal manometry and rectal biopsy for confirmation

Irritable bowel syndrome

Chronic recurrent abdominal pain

Often alternating diarrhea and constipation

Feeling of incomplete evacuation

Passage of mucus

No anorexia or weight loss

Clinical evaluation

Intestinal pseudo-obstruction

Nausea, vomiting

Abdominal pain and distention

Abdominal x-ray

Colonic transit time

Antroduodenal manometry

Intestinal tumor

Weight loss

Night sweats

Fever

Abdominal pain and/or distention

Palpable abdominal mass

Bowel obstruction

MRI

Cerebral palsy and other severe neurologic deficits

In most children with cerebral palsy, which causes intestinal hypotonia and motor paralysis

Tube feedings with low-fiber formulas

Clinical evaluation

Drug adverse effects

Use of anticholinergics, antidepressants, chemotherapeutics, or opioids

Suggestive history

Clinical evaluation

Toxins

Infant botulism

New onset of poor suck, feeding difficulties, anorexia, drooling

Weak cry

Irritability

Ptosis

Descending or global hypotonia and weakness

Possible history of ingestion of honey before age 12 months

Test for botulinum toxin in stool

Lead toxicity

Most likely asymptomatic

Possible intermittent abdominal pain, sporadic vomiting, fatigue, irritability

Loss of developmental milestones

Blood lead level

* Anal position index (API) is calculated as follows:

  • Girls: Distance from anus to fourchette/distance from coccyx to fourchette (normal mean ± SD 0.45 ± 0.08)

  • Boys: Distance from anus to scrotum/distance from coccyx to scrotum (normal mean ± SD 0.54 ± 0.07)

SD = standard deviation.

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