📊 Functional Constipation (Most Common)
• No organic cause; often after painful stool → withholding
• Encopresis: fecal soiling from overflow incontinence
• Treatment: disimpaction + maintenance (laxatives, toileting, behavioral support)
⚠️ Red Flags for Organic Cause
• Delayed passage of meconium (>48h)
• Ribbon-like stools, failure to thrive
• Bilious vomiting, abdominal distention
• Absent anal wink, sacral dimple, neurologic abnormalities
• Down syndrome, Hirschsprung in family
🩺 Hirschsprung Disease
• Congenital aganglionic megacolon
• Delayed meconium (40% of cases)
• Constipation since birth, narrow caliber stools
• Rectal exam: empty ampulla (no stool), explosive stool after withdrawal
• Diagnosis: rectal suction biopsy (absent ganglion cells)
📋 Treatment Approach
• Disimpaction: oral (PEG 3350, senna) or rectal (enema)
• Maintenance: PEG 3350, lactulose, senna, mineral oil
• Toilet training: scheduled sitting, reward system
• Encopresis: treat constipation first; soiling resolves with disimpaction
📌 Decision strategy: Functional constipation is most common. Red flags → evaluate for Hirschsprung (rectal biopsy). Encopresis = overflow incontinence from chronic constipation, not intentional.