Inpatient Clinical Pathway for Evaluation/Treatment of Children with Constipation
Related Pathway
Constipation, ED
Constipation, ED
Cystic Fibrosis patients are excluded from this pathway
Red Flags
- First passage meconium after 48 hours of life
- Symptom onset < 1 month
- Persistent abdominal distention, vomiting
- Bloody diarrhea
- Bilious emesis
- Family history Hirschsprung’s disease
- Failure to thrive
- Tight rectum gripping finger; explosive stool and air from rectum upon withdrawal examining finger
- Midline dimple, tuft of hair over lower back
- Lower limb weakness, motor delay
- Signs of systemic illness: fever, mouth sores, joint pain, rash
- Weight loss
1-8 Concern Hirschprung, 7 Malabsorption
- MD/CRNP/RN Rapid Assessment
- History & Physical
- Assess Red Flags, Risk Underlying Disease
- Review Diagnostic Criteria for Constipation
No Red Flags, Low Concern for Underlying Disease
Functional Constipation Likely
Functional Constipation Likely
- Acute Surgical Abdomen
- Hirschprung Disease
- Medical Disease - GI, Metabolic
- Neurologic Disease
Child ≥ 6 Months
No Fecal
Impaction
Impaction
Fecal Impaction and
significant pain, vomiting
significant pain, vomiting
Treatment
Effective
Effective
Matches ED
Skip to 2nd Line Treatment if Admit from ED
Treatment Not Effective
at 1 Hour
at 1 Hour
Clear
Output
Output
Some stool passed.
Abdominal discomfort
improved.
Abdominal discomfort
improved.
Discharge
Treatment
Effective
Effective
Admit from ED
Treatment Not Effective
at 1 Hour
at 1 Hour
Reassess constipation diagnosis and etiology
Review H&P
Reevaluate stool burden
Re-assess for presence of Red Flags
Consider:
Reevaluate stool burden
Re-assess for presence of Red Flags
Consider:
- Diagnostic 2-view XR
- Surgery vs. GI Consult for manual disimpaction or further evaluation
Fecal Impaction
- History of no stool passage > several days
- History of encopresis
- Stool in rectum on digital rectal exam or in the descending colon/rectum on imaging
- Palpable abdominal stool mass on physical exam
Posted: February 2015
Revised: April 2020
Authors: E. Kane, MD; M. Mittal, MD; K. Wagenman, RN; K. Fiorino, MD; C. Jacobstein, MD; R. Verma, MD; X. Morgan, CRNP; S. Peck, APN; C. McIntyre, PharmD; J. Crawford, CNS; A. Shah, MD; L. Utidjian, MD; J. Lavelle, MD
Revised: April 2020
Authors: E. Kane, MD; M. Mittal, MD; K. Wagenman, RN; K. Fiorino, MD; C. Jacobstein, MD; R. Verma, MD; X. Morgan, CRNP; S. Peck, APN; C. McIntyre, PharmD; J. Crawford, CNS; A. Shah, MD; L. Utidjian, MD; J. Lavelle, MD