By: Varla Septrinidya G.

(405090215)
Holding
Puborectalis plus external anal-sphincter
contracting
Skeletal muscle responses
Puborectalis plus external anal-sphincter relax
Levator ani, rectus muscles and diaphragm
contract
Smooth muscle responses
Internal anal sphincter relaxes
Rectal contraction
Constipation describes the infrequent
passage of stools (bowel movements) or the
passage of hard stools.
Newborns younger than 2 weeks should have at
least 1 or 2 bowel movements a day.
Babies older than 2 weeks can go 2 days and
sometimes longer between bowel movements.
Constipation is likely to occur when a baby
changes from breast milk to formula, especially
if this change happens during the first 2 to 3
weeks of life.
A child age 3 or 4 may normally have as many as
3 bowel movements a day or as few as 3 a week.

The most common cause in a child older than 18
months is their willful avoidance of the toilet
(for various reasons).
At school they may be concerned with lack of
privacy or the cleanliness of the bathroom.
Changes in diet, or a different diet affect bowel
habits.
Breastfed infants will generally have more
stools per day.
Teenagers and toddlers who eat a lot of sugar
and desserts are prone to difficult passing of
their stools
Any intense changes in a child-such as
illnesses causing fever, becoming bedridden,
eating less, or dehydration may decrease the
frequency of stools or may harden stools.
Hypothyroidism (reduced activity of the thyroid gland) is
a condition that causes decreased activity of the intestinal
muscles along with many other symptoms.
True constipation in infants and children that has been
present since birth may be from Hirschsprung's disease.
Diabetes
Alterations in blood mineral and electrolyte
levels (especially calciumor potassium) can change the
bowel habits.
Cystic fibrosis
Children with disorders of the nervous system (such
as cerebral palsy, mental retardation, or spinal cord
problems) display a high rate of constipation because they
spend prolonged time in one position, experience
abnormal colon movement, or lack coordination in moving
their bowels.
Some medications can make children more
likely to be constipated. Common
contributors include over-the-counter cold
medications and antacids. Antidepressants,
anticonvulsants, chemotherapy
medications, or narcotic pain
medications (such as codeine) can also
constipation.
Other possible causes of constipation
are depression, coercive toilet
training,attention deficit disorders, and
sexual abuse.

Generally, if a child has fewer than three
bowel movements per week, and the stools
are hard or painful to pass, he or she may
have constipation.
Children often exhibit characteristic
behaviors while trying to keep from having a
bowel movement.
Infants having painful bowel movements may
extend their legs and squeeze their anal and
buttock muscles to prevent passage of stool.
Toddlers often rise up on their toes, rock back
and forth, and hold their legs and buttocks
stiffly.


Vague abdominal pain around the navel
(belly button) or even severe attacks of
abdominal pain
Decreased appetite, nausea, or vomiting
Urinary incontinence, frequent urination,
or bedwetting
Reappearing urinary tract infections

Close attention to the abdominal exam may
reveal distention, tenderness, or hard stool
that can be felt.
Anal inspection will be performed to check for
problems. The The health care practitioner may
perform a digital rectal exam with his or her
finger to check for hard stool in the rectum or to
see if the rectum is dilated.
The stool may need to be tested for blood.
Usually no diagnostic tests or X-rays have to be
performed if the history and exam suggest
constipation. If a medical problem is suspected
as the cause of constipation, blood tests or
other abdominal imaging studies may need to be
performed.
The most useful tool the doctor can use to diagnose
constipation is the history given by the parents. A
doctor needs to know the following:
What is meant when parents use the term constipation
and how long has the condition been present?
What is the size and consistency of the stools?
How frequent are the bowel movements?
Is pain present with stooling and is there blood present?
Is abdominal pain a problem?
Is there poor appetite, weight loss, or poor weight gain?
Are episodes of fecal soiling present?
Does the child use the bathroom at school?
What over-the-counter, herbal, or prescription
medications are being taken?
What type of diet is the child on?

Positive reinforcement is the first step in
giving children the desire to begin regulation
of their bowels.
Bowel retraining is the next step.
Give your child plenty of fluids and juices,
such as prune or apple juice.
A well-balanced meal consisting of whole
bran cereals, fruits, and vegetables (with
less candy and dessert) also helps.
If you are switching from breast milk to
formula, give your baby no more than 30 ml 60
mL of water and no more than 2 times each day
for the first 2 to 3 weeks.
If your child is older than 6 months, add fruit
juices, such as apple, pear, or prune juice, to
relieve the constipation.
After age 6 months, give 7 mL to 30 mL of prune
juice.
At age 9 months, add 22 mL to 45 mL of strained
prunes per day.
If fruit juices do not help, add baby foods with
a high fiber content twice a day.

For children 1 year and older, increase your
child's fiber intake by adding at least 2
servings of fruit, such as apricots, peaches,
pears, raisins, figs, prunes, dates, and other
dried fruits.
Children older than 4 years may be offered
unbuttered, unsalted popcorn as a snack.
Gently massage your child's belly
Do not give laxatives or enemas to children
without first talking to your doctor.

Give plenty of water to the affected child.
Try 2 to 4 ounces of half-strength pear or apple
juice (diluted with water). Alternatively, add one-
half ounce of table syrup to 3 ounces of warm water,
then administer by mouth to soften the stool.
Add two tablespoons of baking soda to a warm
bath. Let your child relax for 5-15 minutes, soaking
in the warm bath.
Applying a warm, moist cloth to the anus can
sometimes stimulate a bowel movement.
To stimulate a bowel movement, a plastic swab
tipped with cotton (Q-tip) with a small amount of
Vaseline ointment can be gently inserted through
the anus (not too far, just the cotton tip) and
promptly removed. Your health care practitioner
may prescribe a glycerin suppository for the same
purpose but with greatest effect.
Treatment usually consists of educating parents
about the cause of the constipation.
Treatment can begin after education. If a child
has a large amount of hard stool present in the
colon, disimpaction will need to be done. In
other words, the stool needs to be removed.
This is done using either oral or rectal
medications, or a combination of both.
After disimpaction, preventing re-accumulation
of hard stools is the key to maintaining good
bowel habits. This usually has to be done with
long-term medication.


To prevent constipation from returning, the
child should make changes in behavior, diet,
and fluid intake.
Long-term use of laxatives for several
months or up to a year may be indicated.
Regular toilet habits have to be started
after each meal to take advantage of the
body's normal urge to empty the bowel.
Continued use of positive reinforcement
with verbal or other rewards or both often
contributes to long-term bowel success.
For babies younger than 12 months:
Breast-feed your baby.
Make sure you are adding the correct amount of
water to your baby's formula.
For babies ages 6 to 12 months, give an extra 60
mL of water twice a day.
Make sure to add only one new food at a time,
and watch for signs of an allergic
reaction or food intolerance.

Make sure your child is drinking enough
fluids.
Add high-fiber foods.
Increase whole-grain foods, such as bran
flakes, bran muffins, graham crackers,
oatmeal, brown rice, and whole wheat
bread.
Make sure your child is not eating or drinking
too many servings of dairy products.
Set a good example for your child by drinking
plenty of fluids and eating a high-fiber diet.

Constipation sometimes becomes a problem
when children start toilet training:
Encourage your child to go when he or she feels
the urge.
Set aside relaxing times for having bowel
movements.
Make sure your child has good foot support while
he or she is on the toilet.
Make sure your child gets plenty of exercise
throughout the day.

Acute constipation can be corrected easily.
After the dehydration or illness improves, bowel
function improves.
Chronic constipation, however, often requires
long-term therapy with oral medication. Most
children respond to therapy and are able to
discontinue medications within a year. Relapses
can be common, especially if the child or
parents do not follow the health care
practitioner's instructions, or medical
intervention is not present. If therapy fails, the
child may need to see a pediatric
gastroenterologist, the doctor who specializes in
the stomach and intestines.
Anorectal disorders: These are the most common causes of
minor rectal bleeding.
Hemorrhoids: Hemorrhoids are swollen rectal veins in the anal and
rectal area. They can cause burning, painful discomfort, and bleeding.
External hemorrhoids are small swellings that are easy to see and quite
painful. Anal itching is common.
Internal hemorrhoids are usually painless. A rectal mass sensation may be
noted with bowel movements.
Symptoms are brought on by hard stools and straining with bowel movements.
Treatment focuses on relieving these symptoms with the use of stool bulking
agents and softeners.
In cases of thrombosed hemorrhoids, a clot forms within the swollen vein. This
causes moderate-to-severe pain and requires minor surgery to remove them.
Rectal fissure: This is a tear in the lining of the rectum caused by the
passage of hard stools.
An occurrence can lead to mild rectal bleeding of bright red blood. Exposed
nerves and vessels result in moderate-to-severe pain. Pain worsens with bowel
movements then stops in between bowel movements.
In both hemorrhoids and rectal fissures, symptoms are generally improved
with use of stool softeners and bulking agents, increasing fiber in the diet,
pain control, and frequent warm water baths.

Diverticulosis: Diverticula are outpouchings that
project from the bowel wall. Their development
is caused by decreased fiber in the diet.
People with this condition are usually older than 40
years, and it generally increases with age.
Stools are dark red or maroon. Pain is usually absent
but, when present, typically occurs in the left
abdomen.
Persistent bleeding may mean hospitalization is
necessary. Surgery is required in up to 25% of these
patients.
Infection: Bacterial dysentery is commonly the
source of infectious, bloody diarrhea.
Responsible organisms include Campylobacter
jejuni, Salmonella,Shigella, Escherichia coli,
and Clostridium difficile.
Physical complaints include abdominal pain, fever,
and bloody diarrhea.
Antibiotics may be given for treatment.

Inflammation: Inflammatory bowel disease is
a common cause of rectal bleeding in young
adults-typically those younger than 50 years.
Bleeding occurs in small-to-moderate amounts of
bright red blood in the rectum, usually mixed in
with stool and mucus. Associated symptoms
include fever and crampy, stomach pain.
Angiodysplasia: This is a vascular problem
that involves enlarged veins and capillaries in
the wall of the right colon. These areas
become fragile and can bleed.
Episodes are found mainly in elderly people.
Rectal bleeding is usually slow, chronic, and not
obvious until massive bleeding occurs. People
complain of weakness, fatigue, shortness of
breath, and painless rectal bleeding

Tumors and polyps:
Polyps: Lumps of tissue or polyps bulge out from the
lining of the colon. Bleeding occurs when large polyps
develop. They can be hereditary. Usually harmless,
some types can be precancerous.
Tumors: Both benign and malignant forms are
frequently found in the colon and rectum. Those
people older than 50 years are most affected.
However, tumors can be found in younger people.
Less than 20% of people with tumor or polyps will
have rectal bleeding. However, when bleeding does
occur, it is usually slow, chronic, and minimal.
If cancerous lesions are advanced, additional
symptoms such as weight loss, a change in the caliber
of stools, a sense of rectal fullness, or
constipation may be experienced.
Diagnosis requires evaluation with colonoscopy.
Trauma: Rectal bleeding from a traumatic cause
is always a critical concern. Rectal damage from
a gunshot wound or foreign body insertion can
result in extensive infection or rapid and fatal
blood loss.
Upper gastrointestinal source: A common
source of rectal bleeding is bleeding from
the upper gut-usually the stomach or
duodenum. This can occur after someone has
swallowed a foreign body that causes injury
to the stomach lining, bleeding stomach
ulcers, or Mallory-Weiss tears.
Intussusception: This condition occurs when
the bowel simply twists upon itself. It is the
most common cause of intestinal
obstruction and rectal bleeding in children
younger than 2 years. The majority of cases
occur within the first year of life.
The 3 cardinal symptoms are intermittent
abdominal pains, vomiting, and rectal bleeding.
However, these are not always present.


Meckel diverticulum: A rare condition, this
occurs in less than 2% of the population. In
fact, only 76 cases have been treated in the
last 4 years. In this condition, gastric lining is
found in an inappropriate location of the
gastrointestinal tract. As a result, the gastric
acid secreted from this lining erodes tissue
and ultimately causing hemorrhage.
Rectal bleeding in a Meckel diverticulum is
painless and appears bright red.

Rectal pain
Bright red blood present in or on the stool
Change in stool color to black, red, or
maroon
Stool test positive for occult blood loss
(blood may present, but you cannot see it)
Confusion
Dizziness or lightheadedness
Fainting

Physical exam: The focus is on finding the source and
extent of bleeding. Priority is to identify significant
low blood volume and begin appropriate treatment.
This is the most life-threatening situation. The
physician will focus on 3 aspects:
Vital signs: Low blood pressure and elevated heart rate
will indicate significant loss of blood. High temperature
will suggest an infectious source.
Abdominal examination: The physician will search for
abdominal distension, discomfort, or tenderness that
may suggest a possible bleeding ulcer. A mass the doctor
can feel is cause for concern about cancer.
Anal and digital rectal examination: The anus will be
inspected for possible external sources of bleeding such
as trauma, foreign body, or hemorrhoids. A finger
examination is performed to assess tenderness,
character of stool, and the presence of masses.

Diagnostic tests: Depending on the type and
severity of bleeding, special tests may be
performed to aid in diagnosis.
Blood tests: Blood samples are taken to assess
the extent of blood loss, the clotting ability of
blood, and the possibility of infection.
Nasogastric tube: A flexible tube is passed
through the nose into the stomach to check for
the presence of active bleeding.
Scope examinations:
Anoscopy: A plastic or metal scope placed into the
anus allows for quick examination of the rectal vault.
Flexible sigmoidoscopy: A flexible tube inserted into
the rectum is used to evaluate the rectum and lower
end of the colon.
Colonoscopy: It is used to locate areas of bleeding,
masses, or irregularities.

Barium enema x-ray: This study uses liquid
barium inserted into the rectum. An x-ray is
taken to highlight problem areas such as tumors
or diverticula. However, sites of active bleeding
cannot be distinguished.
Nuclear medicine studies: A tagged red blood
cell scan may be used to pinpoint areas of slow
bleeding.
Angiography: A contrast dye study is used to
evaluate active areas of brisk bleeding.

If minimal rectal bleeding, such as blood-
streaked toilet tissue, is the source of the
problem, it may be due to hemorrhoids or a
rectal fissure. Home therapy can be
attempted.
Self-care of rectal bleeding may include various
rectal ointments and suppositories. These can be
bought over-the-counter without a prescription.
Still, if your symptoms are not improved within 1
week of treatment or you are older than 40
years, you should see your doctor for further
evaluation.

Simple home care of rectal bleeding might
involve these actions:
Drink 8-10 glasses of water per day.
Bathe or shower daily to cleanse the skin around
the anus.
Decrease straining with bowel movements.
Increase fiber in the diet with supplements such
as Metamucil or foods such as prunes.
Avoid sitting on the toilet too long.
Apply ice packs to the affected area to decrease
pain.

Regardless of the source of bleeding,
treatment of significant blood loss will begin
by stabilizing your condition.
Initially, oxygen will be given and your heart will
be monitored. An IV will be started to administer
fluids and for a possible blood transfusion.
Further treatment options will depend on the
suspected source of bleeding. It is quite likely
that a specialist such as a general
surgeon, gastroenterologist, or colorectal
surgeon will become involved in the treatment
plan.
The majority of people with significant rectal bleeding
are elderly. Members of this population commonly have
many other medical problems. As a result, they tend to
suffer increased rates of illness and death.
In recent years, death from rectal bleeding has significantly
decreased.
Some 80% of acute rectal bleeding episodes will resolve without
treatment.
Yet, 25% of the areas causing this rectal bleeding will re-bleed. This
underscores the need for making a definitive diagnosis and in
discovering the source of the bleeding so that the corrective actions
may be made.
The majority of complications from rectal bleeding occur when
large amounts of blood have been lost.
Rectal bleeding with symptoms of weakness, dizziness, or
fainting is associated with at least 1 liter of blood lost. This
will usually cause you to seek medical care. Sudden loss of 2
liters or more of blood can be dangerous, if not fatal.

Rectal itching (pruritus) is usually not a sign of a serious disease. At first,
the skin of the anal area may appear red. Itching and scratching may
make the skin become thickened and white. Common causes of rectal
itching include:
Poor cleaning of the area after a bowel movement. Itching and discomfort may
occur when pieces of stool become trapped in skin folds around the anus.
Medicines, especially medicines that cause diarrhea or constipation, such as
antibiotics.
Cleaning of the anus with very hot water and strong soaps. The anal area is
normally oily, and this barrier protects against the irritation of bowel
movements.
The use of scented toilet paper, scented soap, or ointments (such as those that
contain benzocaine).
A generalized dry skin condition that affects the entire body. This condition is
more common in older adults.
Hemorrhoids. Hemorrhoids are enlarged veins near the lower end of the rectum
or outside the anus.
An infection of the anus or rectum, which may be caused by viruses (such as
genital warts), bacteria, pinworms, scabies, fungus, yeast, or parasites.
Pinworms are the most common cause of anal itching in children.
Certain foods, such as coffee, tea, cola, alcoholic beverages, chocolate,
tomatoes, spicy foods, and large amounts of vitamin C.
Rectal pain may be caused by diarrhea, constipation, or
anal itching and scratching. Rectal pain caused by these
conditions usually goes away when the problem clears up.
Other less common causes of rectal pain include:
Enlarged, swollen veins in the anus (hemorrhoids).
Structural problems, such as anal fissures and fistulas or rectal
prolapse.
Infection, such as a sexually transmitted disease, prostate
infection, an abscess, or a pilonidal cyst.
Injury from foreign body insertion, anal intercourse, or abuse.
Diseases, such as cirrhosis of the
liver, diabetes, lymphoma, Crohn's disease, or ulcerative
colitis.
Cancer of the rectum or the prostate or skin cancers, such
as squamous cell cancer and Bowen's disease.
Previous treatment, such as surgery or radiation therapy to
the rectum or pelvis.
Rectal spasms (proctalgia fugax).

Poor hygiene. Clean the area gently with water-
moistened cotton balls, a warm washcloth, or
premoistened towelettes, such as Tucks or "baby
wipes." A mild ointment, such as A+D Ointment or
Desitin, can be applied lightly to help soothe the skin
and protect it against further irritation.
Scented or colored toilet paper or scented soaps.
Buy white, unscented toilet paper.
Apply an ointment that contains 1% hydrocortisone. Do
not use other steroid creams on this sensitive area of
your body; skin damage can occur. Hydrocortisone cream
should not be used for longer than 7 to 10 days without
talking with your doctor. Note: Do not use the cream on
children younger than age 2 unless your doctor tells you
to. Do not use in the rectal or vaginal area in children
younger than age 12 unless your doctor tells you to.

Reactions to topical creams. Do not use
creams or ointments, such as Benadryl
cream, that contain antihistamines.
Excessive sweating. For anal itching caused
by excessive sweating, avoid wearing tight-
fitting underwear and wear cotton, rather
than synthetic, undergarments. You may use
talcum powder to absorb moisture, but do
not use cornstarch. Cornstarch may cause
a skin infection. Dry your rectal area with a
hair dryer set on the low setting before
applying talcum powder.

Take an oral antihistamine at night to help lessen your
nighttime itching. Don't give antihistamines to your child
unless you've checked with the doctor first.
Take a warm sitz bath, three times each day and after
each bowel movement. Following the bath, dry the anus
carefully.
Avoid foods that can increase rectal itching, such as
coffee, tea, cola, alcoholic beverages, chocolate,
tomatoes, spicy foods, and excessive amounts of vitamin
C, for a minimum of 2 weeks.
Trim your fingernails short if you find yourself scratching
irritated skin at night. Wear cotton gloves or socks on your
hands at night to help stop the unconscious scratching that
can occur while you sleep.
Control your stress. Being under stress and feeling anxious
or worried can cause some people to experience skin
itching.

When you have rectal bleeding, do not
take aspirin and other nonsteroidal anti-
inflammatory drugs (NSAIDs). Aspirin and
other NSAIDs, such as ibuprofen, can cause
bleeding in the digestive tract, which can
increase the amount of blood in your stools.
These medicines can also make bleeding
hemorrhoids bleed more. If you need to use
something for pain, try
taking acetaminophen, such as Tylenol.
Rectal bleeding can be caused by
constipation, diarrhea, and hemorrhoids.

Use white, unscented toilet paper.
Do not use scented soaps, such as Irish Spring and Coast, which
can irritate skin.
Practice good hygiene.
Do not sit on the toilet for long periods of time.
Eat a high-fiber diet that includes plenty of fruits and vegetables,
and bran cereal every day.
Avoid foods that can cause rectal problems. Examples of such
foods include:
Regular or diet cola.
Coffee.
Beer and other alcoholic beverages.
Dairy products.
Any other items that you know cause you to have gas or indigestion.
Avoid constipation.
Avoid diarrhea.

There are many different types of worm infection,
but the most common in the UK generally cause only
minor illnesses. These include:
Threadworms - also known as pinworms - are the most
common parasitic worms in the UK. They're tiny (about
1cm long), pale, thin worms that look like cotton
threads and thrive in the intestines.
Roundworms - also known asnematodes, are larger,
some look more like garden worms and also live in the
intestines. They are less common than threadworms.
Tapeworms also known as cestode, are long ribbon-like
worms that can be caught from undercooked meat and
fish and contaminated water.
Other worms - tapeworms and flukes - are also
occasionally problematic in the UK.


The main symptom of threadworms is itching
around the anus or vulva. This is worse at night
when the worms come to the skin surface to lay
eggs. The worms may also be seen on faeces.
Round worms usually do not cause any symptoms
although they the toxocara canis worm can lead
to visual problems when they migrate to the
eye and cause inflammation and scarring of the
retina. The worms may also move to the lungs,
causing a cough and asthma, and lead to swelling
in other body organs.
Tapeworms may cause vague abdominal
symptoms. They may become encysted in
muscle, skin, heart, eye and brain.

Threadworms are usually passed on by poor hygiene.
Children easily pick up threadworms from each other
through contact with skin or objects contaminated with
the eggs of worms. These enter the mouth and grow into
adult worms in the gut. Poor hygiene, particularly not
washing hands after using the toilet, is a major factor in
the spread of infection.
Exposure to cat and dog faeces can cause toxocara worm
infections. Pregnant women and children should steer
clear of litter trays and always wash their hands after
contact with pets.
Tapeworms can be caught from pets and occasionally when
children accidentally swallow a dog flea infected with the
worm.
Threadworms can be diagnosed by seeing the worms in or
on faeces, or by collecting a sample of their eggs by
pressing a small strip of sticky tape to the skin around the
child's anus as soon as they wake in the morning.

Anti-parasitic drugs are used to treat
threadworms, and a single dose may be all that
is needed. All the family should be treated at
the same time.
Toxocara worms can be diagnosed using a
blood test, but need specialist investigation and
treatment. Anti-parasitic drugs are used for this
and other worm infections.
Careful hygiene can reduce the risk of worm
infections. Pets should be wormed regularly and
the garden kept clear of faeces. Children should
wash their hands after playing with animals and
be taught not to put soil into their mouths.