Emergency Provider Use of Plain Radiographs in the Evaluation of Pediatric Constipation

Abstract

Background: Abdominal pain is the fourth most common pediatric outpatient complaint, with over half eventually being diagnosed with constipation. X-ray use in the evaluation of constipation is variable: 4% in outpatient/clinic settings but over 70% of children with constipation evaluated in an emergency department. X-rays use increases misdiagnosis rate, remains costly, and involves radiation exposure. Objectives: To assess the use of plain radiographs by Pediatric Emergency Medicine (PEM) providers in the routine diagnostic evaluation and management of pediatric constipation Methods: A cross-sectional, quarterly survey of pediatric emergency medicine providers was performed. Survey participants were subscribers to the American Academy of Pediatrics Section On Emergency Medicine (AAP-SOEM) list-serv. Participants were presented a case of pediatric constipation meeting Rome-III clinical criteria to assess both diagnostic and therapeutic approaches. Participants were asked to categorize frequency of x-ray use, reasons for obtaining, estimated diagnostic utility, and elements of institutional standard diagnostic approach to constipation, if applicable. Descriptive statistical analyses were performed. Results: 305 of 1272 eligible list-serv members (24%) responded, with 272 complete surveys. 86% were PEM-boarded with over half more that 10 years since completing fellowship. 99% elected to treat for constipation a child meeting Rome-III clinical criteria; one-third (31%) would obtain plain radiographs for this same child. Plain radiographs were viewed as somewhat (59%) or minimally (29%) valueadded in the clinical evaluation of suspected pediatric constipation. The most common reasons for obtain plain radiographs were: obtaining family buy-in (44%) and ruling out other diagnosis (19%). Frequency of x-ray use varied across geographic regions and with participant and hospital characteristics. Conclusion: This survey suggests that many physicians are obtaining radiographs to convince families of the diagnosis of constipation. This is not a viable management plan given the risks of radiation as well as financial costs to the family and medical system. There remains room for improvement as we attempt to reduce use of ionizing radiation in the evaluation of common pediatric illnesses.

Qualitative Point-of-Care Ultrasound Enema Management for Constipation

“…[13][14][15] Therefore, POCUS could replace harmful radiography to act as a visual aid to promote collaboration with management plans. 16 Our case series suggests that a simplified qualitative assessment of rectal contents could replace both digital rectal examinations and the quantitative TRD measurement that may be prone to measurement error and creates complexity when choosing a reliable cut-off value.…”

“…Clinicians have been urged to avoid abdominal radiography to “rule-in” constipation, given limitations in test characteristics and its association with delayed or missed diagnosis 13–15 . Therefore, POCUS could replace harmful radiography to act as a visual aid to promote collaboration with management plans 16 . Our case series suggests that a simplified qualitative assessment of rectal contents could replace both digital rectal examinations and the quantitative TRD measurement that may be prone to measurement error and creates complexity when choosing a reliable cut-off value.…”

The burden of pediatric emergency departments, constipation: a systematic review

“…Constipation accounts for more than half of abdominal pain. While the use of abdominal X-rays for the diagnosis of constipation in outpatient clinics is 5%, this rate rises to 70% in emergency services [ 7 ]. In our study, imaging was performed in 1325 (40.5%) of the patients who applied to the emergency department.…”

Inter and Intraobserver Variation in Interpretation of Fecal Loading on Abdominal Radiographs

“…Although thorough history taking, physical examination, and fulfillment of Rome IV criteria are sufficient to make a diagnosis of functional constipation, tests such as abdominal radiography are still being used to diagnose constipation despite current ESPGHAN/NASPGHAN recommendations (9). This can lead to unnecessary radiation, unnecessary use of laxative therapy, and referrals to GI (10,12). This study was designed to understand the discrepancy among physician’s interpretation of fecal loading on abdominal films during routine evaluation of patients with abdominal pain or suspected constipation.…”