Rectal examination in paediatric surgical practice

The Role of Digital Rectal Examination for Diagnosis of Acute Appendicitis: A Systematic Review and Meta-Analysis

BACKGROUND

Digital rectal examination (DRE) has been traditionally recommended to evaluate acute appendicitis, although several reports indicate its lack of utility for this diagnosis. No meta-analysis has examined DRE for diagnosis of acute appendicitis.

OBJECTIVES

To assess the role of DRE for diagnosis of acute appendicitis.

DATA SOURCES

Cochrane Library, PubMed, and SCOPUS from the earliest available date of indexing through November 23, 2014, with no language restrictions.

STUDY SELECTION

Clinical studies assessing DRE as an index test for diagnosis of acute appendicitis.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted study data and assessed the quality, using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Bivariate random-effects models were used for the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio (DOR) as point estimates with 95% confidence intervals (CI).

MAIN OUTCOMES AND MEASURES

The main outcome measure was the diagnostic performance of DRE for diagnosis of acute appendicitis.

RESULTS

We identified 19 studies with a total of 7511 patients. The pooled sensitivity and specificity were 0.49 (95% CI 0.42-0.56) and 0.61 (95% CI 0.53-0.67), respectively. The positive and negative likelihood ratios were 1.24 (95% CI 0.97-1.58) and 0.85 (95% CI 0.70-1.02), respectively. The DOR was 1.46 (0.95-2.26).

CONCLUSION AND RELEVANCE

Acute appendicitis cannot be ruled in or out through the result of DRE. Reconsideration is needed for the traditional teaching that rectal examination should be performed routinely in all patients with suspected appendicitis.

Evaluation and management of acute abdominal pain in the emergency department

Evaluation of the emergency department patient with acute abdominal pain is sometimes difficult. Various factors can obscure the presentation, delaying or preventing the correct diagnosis, with subsequent adverse patient outcomes. Clinicians must consider multiple diagnoses, especially those life-threatening conditions that require timely intervention to limit morbidity and mortality. This article will review general information on abdominal pain and discuss the clinical approach by review of the history and the physical examination. Additionally, this article will discuss the approach to unstable patients with abdominal pain.

Utility of the digital rectal examination in the emergency department: a review

BACKGROUND

The digital rectal examination (DRE) has been reflexively performed to evaluate common chief complaints in the Emergency Department without knowing its true utility in diagnosis.

OBJECTIVE

Medical literature databases were searched for the most relevant articles pertaining to: the utility of the DRE in evaluating abdominal pain and acute appendicitis, the false-positive rate of fecal occult blood tests (FOBT) from stool obtained by DRE or spontaneous passage, and the correlation between DRE and anal manometry in determining anal tone.

DISCUSSION

Sixteen articles met our inclusion criteria; there were two for abdominal pain, five for appendicitis, six for anal tone, and three for fecal occult blood. The DRE was shown to add no additional diagnostic information and confounded the diagnosis in acute, undifferentiated abdominal pain. The sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio for the DRE were too low to reliably diagnose acute appendicitis in children and adults. No statistical differences in the number of colonic pathologies were found between stool collection methods in those with positive FOBT. The DRE correlation with anal manometry in determining resting and squeeze anal tone ranged from 0.405 to 0.82 and 0.52 to 0.97, respectively.

CONCLUSION

We found the DRE to have a limited role in the diagnosis of acute, undifferentiated abdominal pain and acute appendicitis. Stool obtained by DRE doesn't seem to increase the false-positive rate of FOBTs, and the DRE correlated moderately well with anal manometric measurements in determining anal sphincter tone.

Approach to acute abdominal pain

Evaluation of the emergency department patient with acute abdominal pain may be challenging. Many factors can obscure the clinical findings leading to incorrect diagnosis and subsequent adverse outcomes. Clinicians must consider multiple diagnoses with limited time and information, giving priority to life-threatening conditions that require expeditious management to avoid morbidity and mortality. This article seeks to provide the clinician with the clinical tools to achieve these goals by reviewing the anatomic and physiological basis of abdominal pain and key components of the history and the physical examination. In addition, this article discusses the approach to unstable patients with abdominal pain.

Abdominal pain among children re-evaluation of a diagnostic algorithm

AIM: To re-evaluate the algorithm that has been used for over 40 years for diagnosis of acute abdominal pain among children.

METHODS: Among the 937 cases admitted to the surgical emergency ward in 2000, 656 cases of acute appendicitis were studied to evaluate the usefulness of the present algorithm for its calculated accuracy, false positive and false negative rates, the sensitivity and specificity in the instant diagnosis of various types of acute appendicitis in different age groups. The algorithm used was established in 1958 and revised for this study in 1999. It includes a 3-step analysis of clinical presentations, i.e.: firstly, a diagnosis of surgical pain by definite organic abdominal signs; then a diagnosis of the subgroup of surgical condition by special signs; and finally the diagnosis of the present disease by specific signs. A footnote describes a "comparative technique" of abdominal examination in non-cooperative children.

RESULTS: The general accuracy of diagnosis was 92.8%, overall mortality 0.1% among 973 cases of abdominal pain in 2000.373 attending surgeons and 241 residents including trainees joined the diagnosis and treatment with no remarkable difference in the results. The incidence of acute appendicitis, 656 in 973 cases, was 67.4% representing the majority of abdominal pain. In the series of 656 cases, the accuracy of diagnosis of acute appendicitis was 93.6%, false positive 6.4%, false negative 0.9%, sensitivity at first visit 82.7%, specificity for appendicitis 98.0%, no death or documentary complication.

CONCLUSION: The present algorithm used for diagnosis of acute abdominal pain is effective and preferable in reducing misdiagnosis and maltreatment at emergency. The use of some modern technology should be further explored.