14781-koppen

288 Chapter 14 DISCUSSION Our survey results show that the diagnostic and therapeutic approach towards children with intractable FC differs considerably even among physicians with interest and expertise in the fields of pediatric surgery and pediatric gastroenterology. This emphasizes the need for more studies on this topic and the development of evidence-based guidelines for children who respond poorly to optimal pharmacological management. Furthermore, it is necessary to assess why the available guidelines are poorly adhered to, a problem that has been described before 13,14 , and how to improve guideline adherence. Diagnostic work-up It has been reported that many physicians are reluctant to perform a digital rectal examination in children. 15 However, a digital rectal examination can provide valuable information on the presence of a rectal fecal mass (one of the six diagnostic Rome III criteria for FC) and be helpful in the assessment of anorectal sensation and sphincter tone. 16–18 Among the responders of this survey, the vast majority of physicians performed digital rectal examination routinely or occasionally. This result may be related to the fact that the majority of responders worked in pediatric surgery, where patients are often referred for suspected anatomical problems and with severe long-lasting symptoms, which makes it essential to rule out organic causes of constipation. An interesting finding was that the vast majority of responders (93%) used abdominal X-rays either routinely or occasionally. Multiple studies have shown that there is insufficient evidence to support the use of plain abdominal X-rays as a diagnostic tool in children with functional defecation disorders. 1,19,12,20–22 There is no clear association between clinical symptoms of constipation and fecal loading as determinedby abdominal X-ray. 22,23 Moreover, the sensitivity and specificity of the different scoring systems used to evaluate fecal loading based on abdominal X-rays (Barr, Leech, Blethyn) are unsatisfactory, with low inter- and intraobserver reliability. 22 The finding that none of these scoring systems was used by the responders is likely a consequence of the low reliability of this diagnostic tool in clinical practice. However, if this modality is to have clinical value, a novel reliable and objective method for evaluation is needed, since the lack of a standardized method to assess these radiologic images may lead to inaccuracy and substantial differences in interpretation. In this survey, contrast enemas were commonly used in the diagnostic work-up of children with FC. Although contrast enemas are not a valid alternative to rectal biopsy or anorectal manometry to exclude or diagnose Hirschsprung's disease 1 , they can be helpful to identify anatomical abnormalities in children with constipation (e.g., megarectum or megasigmoid).