By Susan S. Baker
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27 . Behavior 28 . Reassurance . Observation modification . Psych evaluation / Rx Rectal manometry and/or biopsy 30 31 29 Positive for Hirschsprung disease? Yes Surgical management 33 32 No Consider time-limited Rx with : . Cisapride . Biofeedback . PEG solution . training . Stimulant laxatives . Bowel Intensive psych 34 No Yes Treatment effective? 35 . Maintain Rx . Wean Consider other tests : . MRI of spine . Barium emena . Anorectal . Full-thickness biopsy . manometry metabolic tests . Colonic manometry .
Full-thickness biopsy . manometry metabolic tests . Colonic manometry . Other Psych evaluation/Rx . Transit time . Inpatient observation 36 Yes Relapse? 37 38 No Yes Abnormal? No Observation 39 Treatment 40 Re-evaluate 41 42 . History . Physical exam . Occult blood (if indicated) Constipation : Delayed or difficult defecation for > 2 weeks 1 2 Condition Delayed passage of meconium? Yes Rectal biopsy 3 Question 4 No No Action Yes Hirschsprung disease? 5 Sweat test Surgical management 6 7 Yes . Evaluate further .
10 Yes Treatment : . Education . Diet Probably normal (prune, other juices and fruits, fluids, verify formula preparation) 13 12 Yes Treatment effective? 14 No Medication : . Lactulose or Sorbitol . Malt extract . Corn syrup . Occasional glycerin suppository 15 . Re-assessment . Adherence? Re-education No Treatment effective? 17 16 Yes Treatment effective? Yes Maintenance therapy 18 19 No Yes . T4 . Celiac disease . TSH antibodies . Calcium . Sweat test Relapse? 20 No 21 to 23 . Wean . Observe 22 from 28 from 21 to 19 Abnormal T4, TSH, Ca, Pb?
Algorithm for Evaluation and Treatment of Constipation by Susan S. Baker