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

Recommendations for Choosing Wisely in Pediatric Emergency Medicine: Five Opportunities to Improve Value

Unnecessary diagnostic tests and treatments in children cared for in emergency departments (EDs) do not benefit patients, increase costs, and may result in harm. To address this low-value care, a taskforce of pediatric emergency medicine (PEM) physicians was formed to create the first PEM Choosing Wisely recommendations. Using a systematic, iterative process, the taskforce collected suggested items from an interprofessional group of 33 ED clinicians from 6 academic pediatric EDs. An initial review of 219 suggested items yielded 72 unique items. Taskforce members independently scored each item for its extent of overuse, strength of evidence, and potential for harm. The 25 highest-rated items were sent in an electronic survey to all 89 members of the American Academy of Pediatrics PEM Committee on Quality Transformation (AAP COQT) to select their top ten recommendations. The AAP COQT survey had a 63% response rate. The five most selected items were circulated to over 100 stakeholder and specialty groups (within the AAP, CW Canada, and CW USA organizations) for review, iterative feedback, and approval. The final 5 items were simultaneously published by Choosing Wisely United States and Choosing Wisely Canada on December 1, 2022. All recommendations focused on decreasing diagnostic testing related to respiratory conditions, medical clearance for psychiatric conditions, seizures, constipation, and viral respiratory tract infections. A multinational PEM taskforce developed the first Choosing Wisely recommendation list for pediatric patients in the ED setting. Future activities will include dissemination efforts and interventions to improve the quality and value of care specific to recommendations.

Prospective assessment of entrance skin dose and targets for radiation reduction during abdominal plain films in pediatric urology patients

INTRODUCTION

Abdominal radiographs are frequently used for evaluation of bowel and bladder dysfunction in pediatric urology. However, the dose of radiation delivered with each study is estimated from machine settings as opposed to measurement of the true entrance skin dose. In addition, the correlation of radiographic constipation with patient symptoms has been questioned.

OBJECTIVE

To evaluate the practices for obtaining abdominal radiographs and the true entrance skin dose of radiation for each examination in order to identify targets for radiation reduction.

STUDY DESIGN

Pediatric urology patients were prospectively enrolled from June 2022 through June 2023. Dosimeters were attached to the navel to collect entrance skin doses from single view abdominal x-ray. Estimated doses were compared to measured entrance skin dose as well as patient characteristics. Exam parameters were evaluated to identify targets for radiation reduction.

RESULTS

A total of 75 patients were recruited for this study with a median age of 10.0 years (IQR 6-14). Most evaluations were done to assess for bowel and bladder dysfunction (68 exams, 91%). The protocol for exams was not standardized resulting in 27% of patients undergoing a medium or high dose strength and 55% undergoing 1 or more image. The median estimated dose was 0.63 mGy (IQR 0.3-1.2 mGy). The median measured dose was 0.77 mGy (IQR 0.31-2.01 mGy) which was significantly different than the estimations (p < 0.001). The estimated dose, measured dose and estimate error were all found to be positively correlated with patient characteristics including age and body mass index (See Figure). Increasing age and body mass index also showed a higher likelihood of increased dose strength and image acquisition.

DISCUSSION

The measured entrance skin dose of radiation is significantly higher than prior estimates. The measured dose but also the estimate error increased with patient age and size which is likely related to higher settings used for image acquisition as patients age. Standardized protocols using low dose settings and limiting image acquisition to the pelvis may reduce radiation exposure in children with bowel and bladder dysfunction while providing adequate diagnostic data.

CONCLUSION

Radiation dose for abdominal radiographs is higher than previously estimated. Older and larger children received higher doses which may be mediated by increased dose strength and image acquisition. Standardization of protocols could lower radiation exposure.

Qualitative Point-of-Care Ultrasound Enema Management for Constipation

ABSTRACT

We discuss 10 cases where the qualitative evaluation of hard stool in the rectum with point-of-care ultrasound helped guide enema administration in a pediatric emergency department. Point-of-care ultrasound findings were especially valuable in cases where the presenting symptoms were undifferentiated, a language barrier was present, or the guardian and child denied that constipation was an active problem. When sodium phosphate enema administration was done in the pediatric emergency department, evacuation of the rectal stool burden was observed in most cases before final disposition.

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

OBJECTIVES

The current gold standard for the diagnosis of functional constipation is the ROME IV criteria. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and North American Society for Pediatric Gastroenterology, Hepatology & Nutrition (NASPGHAN) guidelines do not support the use of abdominal X-rays in establishing the diagnosis of constipation. Despite these recommendations, abdominal radiography is frequently performed to diagnose constipation. The objective of our study is to evaluate inter and intraobserver variation in interpretation of fecal loading on abdominal radiographs.

METHODS

Electronic records of 100 children seen in the emergency room for gastrointestinal symptoms who had an abdominal radiograph performed were included. Four physicians from each specialty including gastroenterology, radiology, and emergency medicine interpreted the radiographs independently. Initially, subjective interpretations, followed by interpretations for intraobserver variation were obtained. Subsequently, all physicians were trained and asked to score the X-rays objectively using Barr and Blethyn scoring systems. Consistency between inter and intraobserver ratings of radiographic interpretation was evaluated using the Kappa coefficient ( k ) which ranges from 0 (no agreement) to 1.0 (perfect agreement).

RESULTS

For subjective interpretations, k values showed a fixed margin k of 0.18 indicating poor agreement among 12 observers. Intraobserver k to look for reproducibility showed significant variability ranging from 0.08 (poor) to 0.61 (fair) agreement. Objective scoring results for Blethyn showed a k of 0.14 indicating poor agreement among 12 providers.

CONCLUSIONS

Reliability and reproducibility of X-rays for diagnosis and grading of constipation is questionable given poor to fair agreement for both inter and intraobserver comparisons. Our study supports the current recommendation of ESPGHAN and NASPGHAN to not use abdominal X-rays to diagnose constipation.

Colonic stool burden on computed tomography does not correlate with bowel habit: a cross-sectional study

PURPOSE

Stool burden on abdominal radiographs is not reflective of constipation, perhaps because of variable fecal shadowing or limited inter-rater agreement. These limitations are hypothetically mitigated by computed tomography (CT). This research aimed (i) to evaluate whether bowel movement frequency, stool form, or a diagnosis of functional constipation correlate or associate with stool burden identified on CT, and (ii) to investigate whether physicians use CT in their assessment of a patients' bowel function.

METHODS

Patients attending for non-emergent abdominal CT imaging were invited to participate by completing a bowel questionnaire. Stool burden identified on imaging was determined and inter-rater reliability was evaluated in a subgroup of patients (n = 20). Descriptive and comparative analyses were performed. An online questionnaire evaluated the use of abdominal imaging in assessing patients' bowel function in a cross-section of ordering physicians.

RESULTS

The patient response rate was 19% (96/516). No clinically useful associations between fecal burden and stool form, bowel motion frequency, gastrointestinal symptoms or a diagnosis of constipation was identified. The physician response rate was 35% (33/94). Opportunistic use of data was more common than deliberate use. However, an abdominal radiograph or CT scan had been requested by 42% and 18% of physicians respectively to assess patient's chronic bowel habit. Approximately 30% of physicians believed evidence supported this practice.

CONCLUSIONS

Physicians may use abdominal CT in their assessment of patients' chronic bowel habits. However, objective assessment does not support this practice. Colonic stool burden does not correlate with patient-reported symptoms or a criteria-based diagnosis of constipation.

Pediatric Abdominal X-rays in the Acute Care Setting - Are We Overdiagnosing Constipation?

Introduction

Constipation represents 3% of all office visits to pediatricians and 10% - 45% of consultations with pediatric gastroenterologists. It has been reliably established that the role of abdominal x-rays (AXR) in the diagnosis of constipation in pediatrics is limited; yet, significant overdiagnosis of constipation exists when plain abdominal x-rays are used in the acute setting for abdominal pain or to screen for other disorders. This results in loss of time, resources, exposure to unnecessary radiation, and potentially missing the primary diagnosis. The purpose of this study is to determine the sensitivity and specificity of AXR in diagnosing constipation in the acute setting.

Objectives

To determine 1) the sensitivity and specificity of plain AXR in the diagnosis of constipation and 2) the effect of age, race, gender, comorbid conditions, and practice setting on the diagnosis of constipation.

Methods

This study was a historical cohort study of children (two to 18 years of age) who were seen at Ascension St. John Children’s Hospital between March 2015 - March 2018 and who had a plain AXR performed during an emergency department (ED) visit or inpatient stay. If AXR results contained keywords, such as “constipation,” “stool load,” “fecal retention,” and “fecal load,” the ambulatory medical record, Athena® (http://www.athenahealth.com), was searched to determine if the child had an ambulatory visit in the ensuing 45 days. Chart review was conducted to assess if the diagnosis of constipation was later confirmed by history and physical examination by a pediatrician or gastroenterologist at that visit. By comparing data from both encounters, the sensitivity and specificity of plain AXR in diagnosing constipation was assessed. All data were analyzed using the Statistical Package for Social Sciences (SPSS), v. 25.0 (IBM SPSS Statistics, Armonk, NY) and a p-value of 0.05 or less was considered to indicate statistical significance.

Results

Over the three-year study period, 1,383 AXRs were performed on 1,116 patients. The sensitivity of AXR in the diagnosis of constipation was 73.8%, specificity 26.8%, positive predictive value 46.4%, and negative predictive value of 54.3%. Pediatric gastroenterologists were more likely to diagnose constipation (63.2%) compared to pediatricians (41.4%) and pediatric surgeons (33.3%) (p = 0.04).

Conclusions

AXRs are not a reliable means of diagnosing constipation. Overall, we found similar sensitivity and specificity of AXR in diagnosing constipation compared to previous studies. Yet, our study gives new insight into the practices around diagnosing constipation in a single-center community hospital pediatric acute setting and the radiology department. This further emphasizes the need to review current practices and impart more education both in the acute care setting and radiology department.