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Three Part Question

In a [child presenting with constipation] is a [digital rectal examination] recommended to [confirm the diagnosis]?

Clinical Scenario

A five year boy is presented to the Emergency department by his mother. His mother complains that he has constipation. After examining the boy's abdomen you wonder whether in order to confirm the diagnosis you should perform a digital rectal exam (DRE).

Search Strategy

Medline using the OVID interface 1950 to January Week 2 2010: (constipation.mp OR exp Constipation/ exp Feces/ or exp feces impaction/ or stool$.mp OR faec$.mp) AND ([rect$ adj exam].mp OR digital rectal examination.mp OR exp Digital Rectal Examination/). Limit to human and English and all child 0–18 years
Embase 1980-present via the NLH interface: (constipation.ti.ab OR exp Constipation/ exp Feces/ or exp feces impaction/ or stool$. ti.ab OR faec$. ti.ab) AND ([rect$ adj exam]. ti.ab OR digital rectal examination. ti.ab OR exp Digital Rectal Examination/). Limit to human and English and (newborn infant or infant or preschool child or child or adolescent).

The Cochrane Library January 2010: MeSH descriptor Digital Rectal Examination explode all trees.

Search Outcome

46 papers were found, of which 4 articles were useful.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Safder S, et al 2006 USA	96 children aged between 0 and 16 presenting to a specialist clinic with constipation, encopresis or rectal bleeding. DRE performed in only 14 (15%) of the patients before referral. Compared to 96% by the specialist.	Survey	Result of the DRE	The DRE performed by the specialist resulted in diagnoses of faecal impaction, hard stools and anal fissure	The paper is focussed on the effect of DRE on referral rates. It wasn't clear in the study whether the diagnoses could have been arrived at without a DRE
Scholer SJ, et al, 1998 USA	1140 consecutive children aged between 2 and 12 years presenting with abdominal pain that had lasted for 3 days or more. 56 children (4.9%) had a DRE. Of whom 6 had constipation	Survey	Clinical contribution of the DRE	In 12 children (21% of patients who had the DRE) the DRE contributed clinically	The study was not specific to the usefulness of DRE in constipation. The study was aimed more towards the usefulness of DRE in abdominal pain as a whole. The term clinically contributing was not specific, the study did not determine whether the management of the child changed because of the findings on DRE
Gold DM et al, 1999 USA	128 children aged between 1 month and 13 years old referred to a specialist gastroenterology clinic. 98 (77%) children had not had a DRE prior to referral	Survey	Effect if any DRE had on treatment	Of the 128 patients, 66 (52%) had been on stimulant laxative therapy prior to referral, of these patients 47 (71%) had not had a DRE	The paper is focussed on the effect of DRE on referral rates. The paper did not report whether management would have been altered by DRE
Beckmann KR et al, 2001, USA	251 children aged 2–12 years with abdominal pain requiring abdominal radiography	Diagnostic cohort	Clinical utility of DRE at predicting radiographic constipation	Sensitivity 68.6% Specificity 57.4%

Comment(s)

There is no direct evidence to answer the question posed—none of the papers found look at the particular group of children identified. Two papers that focus on children referred to specialist clinics suggest that the use of DRE in clinical practice would decrease the referral rate; the implication is that the management of the referred children would have been improved if a DRE had been performed prior to referral—though neither paper fully explained how management would have been altered. One paper looks at children with protracted abdominal pain from any cause—and the DRE rate is minimal. Finally, another paper concentrated on children referred for abdominal x-ray who have radiographic constipation and shows that DRE is the best predictor of a loaded colon. This, again, says nothing about the value of DRE in routine examination of this group of children and, considering the distress that DRE can cause, could be used to argue for abdominal x-rays for diagnosis. Overall, there is nothing to suggest that DRE should be undertaken in every single patient who presents with possible constipation.

Clinical Bottom Line

TThere is no direct evidence to answer the question posed—none of the papers found look at the particular group of children identified. Two papers that focus on children referred to specialist clinics suggest that the use of DRE in clinical practice would decrease the referral rate; the implication is that the management of the referred children would have been improved if a DRE had been performed prior to referral—though neither paper fully explained how management would have been altered. One paper looks at children with protracted abdominal pain from any cause—and the DRE rate is minimal. Finally, another paper concentrated on children referred for abdominal x-ray who have radiographic constipation and shows that DRE is the best predictor of a loaded colon. This, again, says nothing about the value of DRE in routine examination of this group of children and, considering the distress that DRE can cause, could be used to argue for abdominal x-rays for diagnosis. Overall, there is nothing to suggest that DRE should be undertaken in every single patient who presents with possible constipation.

References

1. Safder S. Rewalt M. Elitsur Y Digital rectal examination and the primary care physicians: a lost art? Clinical Pediatrics 45(5):411-4, 2006 Jun
2. Scholer SJ, et al, Use of the rectal examination on children with acute abdominal pain. Clinical Pediatrics. 37(5):311-6, 1998 May
3. Gold DM, et al, Frequency of digital rectal examination in children with chronic constipation. Archives of Pediatrics & Adolescent Medicine 153(4):377-9, 1999 Apr
4. Beckmann KR, Hennes H, Sty JR, et al. Accuracy of clinical variables in the identification of radiographically proven constipation in children. WMJ 2001;100:33–6.