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By Susan S. Baker

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Extra resources for Algorithm for Evaluation and Treatment of Constipation

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24 . T4 . Celiac disease . TSH antibodies . Calcium . Lead Abnormal Transit time study (if not already done) 25 26 Normal Yes No Soiling? Hirschsprung disease? 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?

MRI of spine . Barium emena . Anorectal . 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 .

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? 23 Yes Evaluate further 24 No Yes Consultation with Pediatric Gastroenterologist Has previous treatment been sufficient? No Treat vigorously 26 Yes No . T4 . Celiac disease . TSH antibodies . Calcium . Sweat test (if not already done) 29 Hirschsprung disease? 30 Rectal manometry and/or biopsy 31 Positive for Hirschsprung disease? Yes 33 32 No Consider other tests : .

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