Inpatient Pathway for the Evaluation/Treatment of
the Child with Constipation
Cystic Fibrosis patients are excluded from this pathway
Red Flags
  1. First passage meconium after 48 hours of life
  2. Symptom onset < 1 month
  3. Persistent abdominal distention, vomiting
  4. Bloody diarrhea
  5. Bilious emesis
  6. Family history Hirschsprung’s disease
  7. Failure to thrive
  8. Tight rectum gripping finger; explosive stool and air from rectum upon withdrawal examining finger
  9. Midline dimple, tuft of hair over lower back
  10. Lower limb weakness, motor delay
  11. Signs of systemic illness: fever, mouth sores, joint pain, rash
  12. Weight loss

1-8 Concern Hirschprung, 7 Malabsorption

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No Red Flags, Low Concern for Underlying Disease
Functional Constipation Likely
  • Acute Surgical Abdomen
  • Hirschprung Disease
  • Medical Disease - GI, Metabolic
  • Neurologic Disease
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Child ≥ 6 Months
No Fecal
Impaction
Fecal Impaction and
significant pain, vomiting
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Treatment
Effective

Initial Treatment per Rectum

Matches ED
Skip to 2nd Line Treatment if Admit from ED

Treatment Not Effective
at 1 Hour
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Clear
Output
Some stool passed.
Abdominal discomfort
improved.
Discharge
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Treatment
Effective
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Admit from ED
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Treatment Not Effective
at 1 Hour
Reassess constipation diagnosis and etiology
Review H&P
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: February 2017, November 2018
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