By Susan S. Baker

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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 : . Barium enema . MRI . Other metabolic tests 34 Yes No Abnormal? 35 Treat accordingly Re-evaluate 36 28 27 25 Surgical management Treatment effective?

Evaluate further . Specialty consultation Are there any red flags? , fever, vomiting, bloody diarrhea, failure to thrive, anal stenosis, tight empty rectum, impaction, 8 distension? No 9 No Functional constipation 11 Exclusively breast-fed > 2 wk old? 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 .

Wean Consider other tests : . 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?

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Algorithm for Evaluation and Treatment of Constipation by Susan S. Baker

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