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Gastroenterology (Expert Forum)
Recent symptoms in child who is a long-term laxative user
Answered by
Kevin Pho, MD - Internal Medicine
Kevin, M.D.
Boston - MA
This forum is for questions regarding Gastroenterology issues such as Acid Reflux (GERD), Barretts Esophagus, Colitis, Colon/Bowel Disorders, Crohn's Disease, Diverticulitis/Diverticulosis, Digestive Disorders, IBS, Stomach Pain.
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Recent symptoms in child who is a long-term laxative user
by truman, Nov 26, 2003 12:00AM
Hi-
At 18 months of age, our extremely easygoing child began screaming and continued until we took her to the ER. An abdominal x-ray showed a large amount of impacted stool in the bowel, and a mass of stool "the size of a potato" in the rectum itself. Several glycerin suppositories produced no movement, so we were instructed to perform a child-sized enema every 12 hours until a movement occurred. After three enemas, she passed a large amount of stool. We saw a pediatric gastroenterologist who examined her and found an anal fissure. He theorized that the fissure (she did have historically large bowel movements, always soft but formed) occurred prior to the impaction, and caused pain. Therefore she began to withhold stool which of course resulted in the constipation and subsequent impaction. He started her on medication, since there was no room in her diet to add more fiber or water.
She is now 30 months old, and is taking 1/4 ExLax plus 1.5 teaspoons of Milk of Magnesia every morning. She still exhibits EXTREME stool withholding behavior, clenching buttocks, standing on tiptoes, etc. She cries and says "No" with every movement, which is difficult to deal with, as she is an unusually happy child and rarely cries unless she is in serious pain. She usually goes once a day. Her stool is always unformed, and usually very watery.
Today she passed about 4 tablespoons of dark yellow mucus with a copious amount of blood in it (probably half of the total amount was blood.) The blood was bright red. A small bowel movement immediately following was also heavily streaked with blood. I am baffled as to how she could possibly have developed a fissure considering she has not had a formed bowel movement in almost a year. I am wondering if there could be any other cause for the blood, and what tests (if any) you think we should ask for. She has never passed mucus or blood like this before, even after her initial fissure. (In fact, we never suspected a fissure because we never saw any blood.)
I am also concerned about the amounts and types of medication she is taking. I am curious as to whether there are any good alternatives. Our ped gi is scheduling two months out, so any information you can provide now is greatly appreciated. I apologize for this being so long, but this entire ordeal has caused all of us a great deal of distress, and I wanted to be sure you had any and all pertinent details so you could answer my questions. Thank you so much for your time.
P.S. She often develops red, pimple-like spots on her lower back, buttocks, and upper thighs, usually 2 or 3 at a time. I am guessing this is not related but wanted to mention it on the off chance it may mean something to you. Otherwise she is perfectly healthy, rarely getting even a cold.
At 18 months of age, our extremely easygoing child began screaming and continued until we took her to the ER. An abdominal x-ray showed a large amount of impacted stool in the bowel, and a mass of stool "the size of a potato" in the rectum itself. Several glycerin suppositories produced no movement, so we were instructed to perform a child-sized enema every 12 hours until a movement occurred. After three enemas, she passed a large amount of stool. We saw a pediatric gastroenterologist who examined her and found an anal fissure. He theorized that the fissure (she did have historically large bowel movements, always soft but formed) occurred prior to the impaction, and caused pain. Therefore she began to withhold stool which of course resulted in the constipation and subsequent impaction. He started her on medication, since there was no room in her diet to add more fiber or water.
She is now 30 months old, and is taking 1/4 ExLax plus 1.5 teaspoons of Milk of Magnesia every morning. She still exhibits EXTREME stool withholding behavior, clenching buttocks, standing on tiptoes, etc. She cries and says "No" with every movement, which is difficult to deal with, as she is an unusually happy child and rarely cries unless she is in serious pain. She usually goes once a day. Her stool is always unformed, and usually very watery.
Today she passed about 4 tablespoons of dark yellow mucus with a copious amount of blood in it (probably half of the total amount was blood.) The blood was bright red. A small bowel movement immediately following was also heavily streaked with blood. I am baffled as to how she could possibly have developed a fissure considering she has not had a formed bowel movement in almost a year. I am wondering if there could be any other cause for the blood, and what tests (if any) you think we should ask for. She has never passed mucus or blood like this before, even after her initial fissure. (In fact, we never suspected a fissure because we never saw any blood.)
I am also concerned about the amounts and types of medication she is taking. I am curious as to whether there are any good alternatives. Our ped gi is scheduling two months out, so any information you can provide now is greatly appreciated. I apologize for this being so long, but this entire ordeal has caused all of us a great deal of distress, and I wanted to be sure you had any and all pertinent details so you could answer my questions. Thank you so much for your time.
P.S. She often develops red, pimple-like spots on her lower back, buttocks, and upper thighs, usually 2 or 3 at a time. I am guessing this is not related but wanted to mention it on the off chance it may mean something to you. Otherwise she is perfectly healthy, rarely getting even a cold.
Doctor's Answer
by Kevin Pho, MD, Nov 28, 2003 12:00AM
, Nov 28, 2003 12:00AM
Inflammatory bowel disease (i.e. Crohn's disease or ulcerative colitis) should certainly be ruled out. This can be manifested by blood in the stool that is not explained by other causes. An endoscopy (i.e. colonoscopy) would be the test of choice.
Red spots on the buttucks and back are indeed significant - thanks for mentioning that. There is a disease known as Henoch-Schönlein purpura - which I think is a more likely scenario in this case. This is a vasculitis (inflammation of the blood vessels) that affects children more than adults. Abdominal symptoms (i.e. pain and GI bleeding) often occur in association to the back and buttock lesions. You may want to keep track of the GI symptoms in relation to when the lesions appear.
Treatment of this disease is with steroids. This should be discussed with your personal physician.
Followup with your personal physician is essential.
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
Thanks,
Kevin, M.D.
Red spots on the buttucks and back are indeed significant - thanks for mentioning that. There is a disease known as Henoch-Schönlein purpura - which I think is a more likely scenario in this case. This is a vasculitis (inflammation of the blood vessels) that affects children more than adults. Abdominal symptoms (i.e. pain and GI bleeding) often occur in association to the back and buttock lesions. You may want to keep track of the GI symptoms in relation to when the lesions appear.
Treatment of this disease is with steroids. This should be discussed with your personal physician.
Followup with your personal physician is essential.
This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.
Thanks,
Kevin, M.D.
I don't think that constipation is a common symptom, but the link I am giving does talk about the fissures, mucus, blood, diarrhea, and dilitation of the colon (megacolon). It even mentions red spots (though on the legs, not back).
http://www.medicinenet.com/Crohns_Disease/page2.htm
hope the doc here can shed some light on everything. I would call the ped GI and mention the blood, and see if they can move the appt up. Be persistent! Call every day to see if there is a cancellation.
http://www.medicinenet.com/Crohns_Disease/page1.htm
sorry.
http://kidshealth.org/parent/general/sick/labtest8.html
a 2 1/2 years old should be able to articulate how and why she is withholding the stool??
it sounds more serious than a fissure.
I am stunned that her spots may be related. The only reason I remembered to mention them is because she happened to have an outbreak right before I posted, which would of course coincide exactly with the questionable bowel movement. I am going to research all of the conditions mentioned in all of the replies, and will certainly ask both her regular ped and her ped gi for further information and testing.
Again, thank you so much for the responses. I never expected to gain so much information from one post! If I learn anything that may benefit this board, I will definitely post it. Thank you, thank you, thank you...