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Colonoscopy
0%
0/7
Proctoscopy
Fiber supplementation
43%
3/7
Laxatives and stool softeners
57%
4/7
Sigmoidoscopy and biopsy
Select Answer to see Preferred Response
A young child coming in with infrequent stools described as pellet-like and an anal fissure is likely suffering from constipation. The child should be treated with laxatives and stool softeners. Anal fissures, particularly in children, are common causes of prolonged periods of constipation. Low fiber diets and large amounts of milk can predispose children to constipation, causing pain and ultimately damage to the anal mucosa. This creates a positive feedback loop where the child does not want to pass stool because of the pain, and this constipation further worsens the anal mucosa, creating ulceration. Nurko et al. review the guidelines for managing constipation in children and adolescents. They state that two or less bowel movements a week along with a history of hard or painful bowel movements are clinically suitable for diagnosis of constipation. They also recommend further work up with imaging or colonoscopy if there are any red flag symptoms such as onset of constipation before one month of age, occult blood in stool, explosive stools, or failure to thrive. Sujatha et al. present the results of a prospective study examining the most common presentation of constipation in children. In a cohort of 531 children, they found that over 66% of the children with constipation presented with painful defecation, with the second and third most common presentations consisting of abnormal posturing and recurrent abdominal pain. They also discovered that the most common epidemiological cohort in their study was females aged 2-4. Incorrect Answers: Answer 1 and 5: A colonoscopy and sigmoidoscopy would not be indicated at this stage of management. There were no concerning signs or family history that warrant anesthetizing the child. Answer 2: A proctoscope can be traumatic for children, but can be used to investigate anal fissures not seen on physical exam. On this patient's exam, an anal fissure was visualized. Therefore, a proctoscopic exam is not needed. Answer 3: The parents should be educated about the child's diet and informed about the role of fiber in long-term good health, but this is not the next best step for the child.
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