Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvantri Nagar, Pondicherry, India.
J Pediatr Gastroenterol Nutr. 2018 Nov;67(5):570-575. doi: 10.1097/MPG.0000000000001969.
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.
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.
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.
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.
功能性便秘指南建议在怀疑便秘或存在器质性病因可疑时进行直肠指检（DRE）。指南并未明确指出 DRE 是否是诊断嵌塞的必需手段。本研究旨在确定在满足罗马 III 标准且无需 DRE 诊断的儿童中，仅通过 DRE 检测到嵌塞的频率，以及 DRE 检测嵌塞的观察者间影响。
评估 6 个月至 13 岁有便秘史的儿童。排除疑似器质性病因、需要 DRE 诊断便秘以及无需 DRE 但不满足罗马 III 标准的儿童后，对其余满足罗马 III 标准的儿童进行触诊可扪及粪石或与便秘相关的粪便失禁以评估嵌塞。没有此类嵌塞的儿童随机分配给 2 名检查者进行 DRE 以诊断嵌塞，如无禁忌证。
评估了 233 名儿童。169 名满足罗马 III 标准且无需 DRE。48 名（28.4%）无 DRE 即可检测到嵌塞。其余儿童中，28 名（30.1%）通过 DRE 发现嵌塞。2 名检查者检测到的嵌塞频率无差异。有 DRE 可检测到嵌塞和无 DRE 可检测到嵌塞的儿童的临床特征相似（P>0.05）。
DRE 确实可以检测到其他方法无法识别的嵌塞病例。这种发现可能在检查者之间具有可比性。可以通过其他临床特征识别这些儿童。从治疗选择的角度来看，需要进一步了解这种发现的临床意义。
