Constipation abdominal x ray

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

An abdominal X-ray may be helpful in the diagnosis of constipation. Findings on an X-ray suggestive of constipation is interpreted according to three scoring system, including Barr, Blethyn, and Leech systems. Barr scoring system is the first scoring method used to interpret abdominal X-ray suggestive of constipation. The total score of more than 10 was postulated as diagnosis of constipation. The revised scoring system of Blethyn (a simplified version of Barr scoring system) is based on the amount of remained feces in large bowel. The Blethyn scoring system consists of 4 grades of fecal retention in bowels. The most studies and organized scoring system for diagnosis of constipation is Leech method. The score of more than 8 is considered as constipation.

Abdominal X-ray

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An abdominal X-ray may be helpful in the diagnosis of constipation. The most common method to diagnose constipation is using Sitzmarks®.
Findings on an X-ray suggestive of constipation in children is interpreted according to three scoring system, including Barr, Blethyn, and Leech systems.

Sitzmarks

Sitzmarks are radioopaque markers which are plastic beads or rings are been contained in a edible capsule.
There are 20-50 rings in each capsule. There are two methods of diagnosis:
- Serial abdominal X-rays are taken after ingestion of the Sitzmarks capsule, until all the rings become cleared from bowels.
- Single abdominal X-ray on the day 5 (after 120 hours) [preferred method due to less radiation exposure].
On the day 5, more than 20% of markers remaining within bowels is diagnostic of delayed colonic transit.^[1]

Barr scoring system

Barr scoring system is the first scoring method used to interpret abdominal X-ray suggestive of constipation.
The main identifier in Barr system is stool retention severity in bowels seen on abdominal X-ray.
The total score of more than 10 was postulated as diagnosis of constipation.^[3]

Scoring elements	Scores
The quantity of stool in ascending colon	0-1-2 points
The quantity of stool in transverse colon	0-2-5 points
The quantity of stool in descending colon	0-3-4 points
The quantity of stool in rectum	0-2-5 points
The quality of the retained stool is expressed in scybala	0-1-2-3 points
The quality of the retained stool is expressed in granular feces	0-2-4-5 points

Blethyn scoring system

The revised scoring system of Blethyn (simplified version of Barr scoring system) is based on the amount of remained feces in large bowel.
The Blethyn scoring system consists of 4 grades of fecal retention in bowels.^[4]

Scoring element	Grade	Constipation severity
Feces in rectum and caecum only	0	Normal
Feces in rectum and caecum and discontinuous elsewhere	1	Mild
Feces in rectum and caecum, continuous and affecting all segments	2	Moderate
Feces in rectum and caecum, continuous elsewhere and dilated colon and impacted rectum	3	Severe

Leech scoring areas-By Mikael Häggström and Nevit Dilmen, via Wikimedia Commons^[5]

Leech scoring system

The most studied and organized scoring system for diagnosis of constipation is Leech method.
Leech divided the colon to 3 different regions in plain abdominal X-ray, include:
1. Ascending colon and proximal transverse colon
2. Distal transverse colon and descending colon
3. Rectosigmoid
The scoring is based on the amount of feces remained in each section (0-5 points).
The score of more than 8 is considered as diagnostic of constipation.^[6]

Scoring element	Scores
No feces visible	0
Scanty feces visible	1
Mild fecal loading	2
Moderate fecal loading	3
Severe fecal loading	4
Severe fecal loading with bowel dilatation	5

Sensitivity and specificity

Sensitivity and specificity of scoring systems for diagnosing constipation are as following:

Author	Year	Scoring system	Sensitivity (%)	Specificity (%)
Barr^[3]	1979	Barr	80	90
Leech^[6]	1999	Leech	76	75
Benninga^[7]	1995	Barr	60	43
Beckmann^[8]	2001	Barr	77	35
Pensabene^[9]	2010	Leech	57	74
Rezazadeh^[10]	2014	Barr	83	79
		Leech	92	80
		Blethyn	79	92

References

↑ Kim ER, Rhee PL (2012). “How to interpret a functional or motility test – colon transit study”. J Neurogastroenterol Motil. 18 (1): 94–9. doi:10.5056/jnm.2012.18.1.94. PMC 3271260. PMID 22323993.
↑ Radiopaedia.org. From the case <“https://radiopaedia.org/cases/37754“>rID: 37754
↑ ^3.0 ^3.1 Barr RG, Levine MD, Wilkinson RH, Mulvihill D (1979). “Chronic and occult stool retention: a clinical tool for its evaluation in school-aged children”. Clin Pediatr (Phila). 18 (11): 674, 676, 677–9, passim. doi:10.1177/000992287901801103. PMID 498690.
↑ Blethyn AJ, Verrier Jones K, Newcombe R, Roberts GM, Jenkins HR (1995). “Radiological assessment of constipation”. Arch. Dis. Child. 73 (6): 532–3. PMC 1511442. PMID 8546512.
↑ <CC BY-SA 3.0> <“https://commons.wikimedia.org/wiki/File%3ALeech_scoring_areas.jpg“>
↑ ^6.0 ^6.1 Leech SC, McHugh K, Sullivan PB (1999). “Evaluation of a method of assessing faecal loading on plain abdominal radiographs in children”. Pediatr Radiol. 29 (4): 255–8. doi:10.1007/s002470050583. PMID 10199902.
↑ Benninga MA, Büller HA, Staalman CR, Gubler FM, Bossuyt PM, van der Plas RN, Taminiau JA (1995). “Defaecation disorders in children, colonic transit time versus the Barr-score”. Eur. J. Pediatr. 154 (4): 277–84. PMID 7607277.
↑ Beckmann KR, Hennes H, Sty JR, Walsh-Kelly CM (2001). “Accuracy of clinical variables in the identification of radiographically proven constipation in children”. WMJ. 100 (1): 33–6. PMID 11315444.
↑ Pensabene L, Buonomo C, Fishman L, Chitkara D, Nurko S (2010). “Lack of utility of abdominal x-rays in the evaluation of children with constipation: comparison of different scoring methods”. J. Pediatr. Gastroenterol. Nutr. 51 (2): 155–9. doi:10.1097/MPG.0b013e3181cb4309. PMC 2910825. PMID 20453675.
↑ REZAZADEH, Afshin; JAVAHERIZADEH, Hazhir; CHAHARDAHCHERIK, Farzaneh; YAVARAHMADI, Mohammad Hossein; SADJADEI, Nooshin; TAHMASEBI, Morteza (2016). “RELIABILITY OF BARR, LEECH, AND BLETHYN SCORE IN USING OF PLAIN RADIOGRAPHY IN DETERMINING FECAL IMPACTION IN CHILDREN WITH AND WITHOUT CONSTIPATION”. Arquivos de Gastroenterologia. 53 (3): 141–145. doi:10.1590/S0004-28032016000300004. ISSN 0004-2803.

Template:WH Template:WS

[pmid22323993-1] Kim ER, Rhee PL (2012). “How to interpret a functional or motility test – colon transit study”. J Neurogastroenterol Motil. 18 (1): 94–9. doi:10.5056/jnm.2012.18.1.94. PMC 3271260. PMID 22323993.

[https://radiopaedia.org/-2] Radiopaedia.org. From the case <“https://radiopaedia.org/cases/37754“>rID: 37754

[pmid498690-3] 3.0 ^3.1 Barr RG, Levine MD, Wilkinson RH, Mulvihill D (1979). “Chronic and occult stool retention: a clinical tool for its evaluation in school-aged children”. Clin Pediatr (Phila). 18 (11): 674, 676, 677–9, passim. doi:10.1177/000992287901801103. PMID 498690.

[pmid8546512-4] Blethyn AJ, Verrier Jones K, Newcombe R, Roberts GM, Jenkins HR (1995). “Radiological assessment of constipation”. Arch. Dis. Child. 73 (6): 532–3. PMC 1511442. PMID 8546512.

[https://creativecommons.org/licenses/by-sa/3.0-5] <CC BY-SA 3.0> <“https://commons.wikimedia.org/wiki/File%3ALeech_scoring_areas.jpg“>

[pmid10199902-6] 6.0 ^6.1 Leech SC, McHugh K, Sullivan PB (1999). “Evaluation of a method of assessing faecal loading on plain abdominal radiographs in children”. Pediatr Radiol. 29 (4): 255–8. doi:10.1007/s002470050583. PMID 10199902.

[pmid7607277-7] Benninga MA, Büller HA, Staalman CR, Gubler FM, Bossuyt PM, van der Plas RN, Taminiau JA (1995). “Defaecation disorders in children, colonic transit time versus the Barr-score”. Eur. J. Pediatr. 154 (4): 277–84. PMID 7607277.

[pmid11315444-8] Beckmann KR, Hennes H, Sty JR, Walsh-Kelly CM (2001). “Accuracy of clinical variables in the identification of radiographically proven constipation in children”. WMJ. 100 (1): 33–6. PMID 11315444.

[pmid20453675-9] Pensabene L, Buonomo C, Fishman L, Chitkara D, Nurko S (2010). “Lack of utility of abdominal x-rays in the evaluation of children with constipation: comparison of different scoring methods”. J. Pediatr. Gastroenterol. Nutr. 51 (2): 155–9. doi:10.1097/MPG.0b013e3181cb4309. PMC 2910825. PMID 20453675.

[REZAZADEHJAVAHERIZADEH2016-10] REZAZADEH, Afshin; JAVAHERIZADEH, Hazhir; CHAHARDAHCHERIK, Farzaneh; YAVARAHMADI, Mohammad Hossein; SADJADEI, Nooshin; TAHMASEBI, Morteza (2016). “RELIABILITY OF BARR, LEECH, AND BLETHYN SCORE IN USING OF PLAIN RADIOGRAPHY IN DETERMINING FECAL IMPACTION IN CHILDREN WITH AND WITHOUT CONSTIPATION”. Arquivos de Gastroenterologia. 53 (3): 141–145. doi:10.1590/S0004-28032016000300004. ISSN 0004-2803.

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