Yield and Examiner Dependence of Digital Rectal Examination in Detecting Impaction in Pediatric Functional Constipation

Objectives: Guidelines on functional constipation recommend digital rectal examination (DRE) when constipation is doubtful or with a suspicion of organic etiology. The guidelines do not clarify if DRE is mandatory to diagnose impaction. This study aims to determine the frequency of impaction detectable only on DRE among children satisfying Rome III criteria without requiring DRE and also the inter-observer influences on impaction detection by DRE. Methods: Children between 6 months to 13 years of age, presenting with history suggestive of constipation were assessed. After excluding those with suspicion of organic etiology, those who needed DRE for diagnosis of constipation and those who do not satisfy Rome III criteria without DRE, the rest who satisfied Rome III criteria were assessed for impaction by palpable fecoliths or constipation-associated fecal incontinence. Those without such impaction were randomized to 2 examiners for DRE to diagnose impaction, in the absence of contraindications. Results: Two hundred and thirty-three children were assessed. One hundred and sixty-nine satisfied Rome III without needing DRE. Forty-eight (28.4%) had impaction detectable without DRE. Among the rest, 28 (30.1%) had impaction by DRE. There was no difference between the frequency of impaction detected by the 2 examiners. Clinical characteristics were similar (P > 0.05) between those with impaction detectable by DRE and those without. Conclusions: DRE does detect cases of impaction not discernible by other means. Such a finding may be comparable between examiners. These children may be identified by other clinical characteristics. The clinical significance of such a finding needs more understanding from the standpoint of therapeutic choices. Address correspondence and reprint requests to Dr Barath Jagadisan, MD, PDCC, Additional Professor, Pediatric gastroenterology, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry 605006, India (e-mail: barathjag@yahoo.com) Received 17 January, 2018 Accepted 12 March, 2018 Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal's Web site (www.jpgn.org). Ethical clearance: The study had been approved by the institute ethic committee that complies with international standards and is registered with the government of India (JIP/IEC/2015/23/830). The authors report no conflicts of interest. © 2018 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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