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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 . 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?

Wean . Observe 17 Yes Abnormal T4, TSH, Ca, Pb? 18 Evaluate further No 19 Consultation with Pediatric Gastroenterologist Has previous treatment been sufficient? 21 20 Yes to 22 No from 21 Impacted? Excess retention? 22 Abdominal x-ray 23 No Yes Excess stool? 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?

Close follow-up 10 . Re-assessment . Adherence? Re-education . Different medication? No Treatment effective? 11 12 Yes Yes Treatment effective? Maintenance therapy 14 13 No Yes Blood tests : . T4 . Celiac disease . TSH antibodies . Calcium . Lead Relapse? 15 No 16 . Wean . Observe 17 Yes Abnormal T4, TSH, Ca, Pb? 18 Evaluate further No 19 Consultation with Pediatric Gastroenterologist Has previous treatment been sufficient? 21 20 Yes to 22 No from 21 Impacted? Excess retention? 22 Abdominal x-ray 23 No Yes Excess stool?

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