Things We Do for No Reason™: Obtaining an Abdominal X-ray to Assess for Constipation in Children

Abstract

Inspired by the ABIM Foundation's Choosing Wisely® campaign, the “Things We Do for No Reason™” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

The Diagnostic Accuracy of Abdominal X-ray in Childhood Constipation: A Systematic Review of the Literature

“…Clinical practice guidelines discourage the use of AXR for the diagnostic workup of children with constipation due to its limited value, misleading nature, and radiation exposure [7][8][9][10][11][12][13][14]. AXR is an imperfect test for the assessment of constipation in children due to the absence of comparative radiologic normative data from children without constipation and the fact that symptoms may not correlate with the extent of faecal loading seen on the AXR or if other factors, such as air in the colon rather than the stool, may play a role in symptomatology.…”

“…While available data discourage the use of AXR for the evaluation of functional constipation in children due to its limited value, radiation exposure, as well as its possible misleading nature [7][8][9][10][11][12][13][14], a significant number of AXRs continue to be performed on children with constipation, particularly in the emergency department [15][16][17][18]. This has led to quality improvement projects that aim to reduce the number of abdominal X-rays performed in such children, with them showing promising results [19][20][21].…”

Imaging of Gastrointestinal Tract Ailments

“…For example, when most radioactivity was retained in the proximal colon and transverse colon, the type of constipation is identified as slow transit [ 259 ]. The efficacy of abdominal X-rays for diagnosing constipation has been investigated in many systematic reviews and retrospective studies, but using abdominal X-rays to evaluate pediatric patients with functional constipation is not beneficial and may be harmful due to frequent radiation exposure [ 260 ]. In addition, studies have shown no diagnostic correlation between clinical symptoms or severity of constipation and abdominal X-ray findings [ 260 ].…”

Things We Do for No Reason™: Routinely hospitalizing children with fecal impaction for inpatient cleanouts

“…13 Similarly, 33% of children presenting to ED with constipation receive abdominal X-rays, 9 despite no evidence of utility in diagnosing constipation and recommendations against routine imaging. 3,14 The use of nasogastric tubes to administer enteral laxatives in the hospital introduces additional risk from tube misplacement or radiation exposure to confirm placement. Furthermore, one study found that patients admitted with fecal impaction "frequently" (not quantified) underwent disimpaction in the operating room despite displaying no signs of bowel obstruction, 4 an extreme manifestation of overtreatment.…”