108 Rectal Examination for Children with Constipation: A Lost Art?

Abstract

Introduction: Constipation has been one of the most common diseases referred to the pediatric gastroenterology clinic, reaching up to 30% of all clinic referrals. Digital rectal examination is the sole direct examination which can assess constipation and its complications including: fecal impaction, soiling, and anal fissures.Aim: To investigate the rectal examination rate performed in children who were referred to our clinic for constipation, encopresis, and/or rectal bleeding.Methods: Constipated children were evaluated for the following data: demographics, diagnosis at referral, performing of digital examination, therapy, digital examination findings by the specialist, and recommended treatment.Results: A total of 94 children participated. The mean age was 7.5 + 4.0 years, and M/F ratio was 1:0.6. The median round trip traveling time for patients was 2.66 hrs (range: 0.3- 4.2 hours). The diagnosis at referral was constipation/ encoprsis in 78 (82%) children, rectal bleeding in 12 (13%), and other in 4 (5%). Diagnostic abdominal X-ray was performed in 14 (15%) children. Rectal examination by PCP prior to referral was only performed in 15 (16%) children vs. 90 (96%) by the specialist. In 4 (4%) children rectal examination was deferred by the specialist due to parental/patient refusal. Rectal examination by the specialist revealed the following findings: empty ampula (rectal vault) in 14 (15%) children, fecal impaction in 18 (19%), anal fissure in 20 (21%), hard stool in 10 (11%), hemorrhoids/fissure in 3 (4%), and anterior anal displacement in 1 (2%). Laxative treatment was given by the primary physicians in 68 (69%) children and rectal enema in 28 (29%). Lavage solution treatment (PEG 3350) was prescribed only in 30 (31%) children.Conclusion: Digital examination is under performed. This practice may cause a misdiagnosis and unjustified referral. Education of primary physicians in constipation for children is clearly warranted.